Psychopathic disorder

In 1994, a report was published by the Department of Health and Home Office Working Party on Mental Disorders, headed by Dr John Reid. The report contained a very informative overview of psychopathic disorder and 28 recommendations for the future, some of which have led to changes in legislation.

The Crimes (Sentences) Act 1997 amended the Mental Health Act 1983, particularly in relation to the management of cases of people segregated from the community under the category of psychopathic disorder. At the time of writing, the Fallon Inquiry into the Personality Disorders Unit at Ashworth Hospital had been published, with 58 recommendations currently being considered by stakeholders. A Department of Health and Home Office Working Party on Psychopathic Disorder will report in 1999.

What is psychopathic disorder?

Walker, citing Pinel, shows that psychiatrists have for many years tended to regard individuals with severe personality disorders and manifestations of aggression and irresponsibility as objects of psychiatric treatment. Over time, changes occurred only in the level of understanding of the topic and in diagnostic terms. Among the latter were manie sans délire, moral insanity, moral imbecility, psychopathy, degenerate constitution, constitutional inferiority, moral insufficiency, sociopathy, and others.

The term 'psychopathy' originated in late 19th century Germany and was originally applied (and still is in continental Europe) to all personality disorders. The term was first narrowed in the United States to apply to individuals displaying antisocial behaviour, and it was in this interpretation that it was imported into England. The term was included in the Mental Health Act 1959 as 'psychopathic disorder'. This general term replaced the earlier terms 'moral insanity' and 'moral defect' used in mental deficiency laws. Despite ongoing debate about the meaning of the term, it was retained in the Mental Health Act 1983. As the Butler Report points out, the legal term 'psychopathic disorder' does not imply a separate diagnostic entity by that name; rather, it is an umbrella term used for the purposes of legal categorization and covers several specific diagnoses. On the other hand, reliable specific diagnoses in this area have yet to be developed. To avoid confusion, the term "psychopathic disorder" should be used solely as a legal concept. It should not be used to describe a clinical condition. Unfortunately, however, confusion cannot be avoided entirely, and, as we shall see in the contents of this chapter, it is sometimes necessary to refer to psychopathic disorder as a clinical condition for the purposes of discussing the available literature.

This legal term includes a number of personality disorders according to ICD-10 and B6M-IV. For example, although dissocial personality disorder according to ICD-10 (B60.2) and antisocial personality disorder according to B5M-IV (301.7) come closest to the clinical understanding of the term "psychopathic disorder", the legal term "psychopathic disorder" is also used in relation to some individuals with paranoid personality according to ICD-10 (B60.0), emotionally unstable personality disorder (including impulsive and borderline type - B60.30, B60.31) according to ICD-10, borderline personality disorder (301.83) according to EBMTU and schizoid personality disorder according to ICD-10 (B6OL). In fact, according to the definition of the Mental Health Act, it includes any personality disorder that results in “severely irresponsible and abnormally aggressive behaviour”. In addition, people with sexual deviations in combination with personality disorders fell into this legal category of psychopathic disorder, although in a psychiatric sense they can also be classified as a non-personality disorder, and are included in such B5M-IV and ICD-10 groups as sexual sadism/sadomasochism, pedophilia and exhibitionism.

Because of the definitional problem, the Butler Commission recommended that the term 'psychopathic disorder' should be dropped. However, despite these difficulties, the term was retained in the Mental Health Act 1983, albeit with some important practical changes. Firstly, it is now clear that a diagnosis of psychopathic disorder under the 1983 Act alone is not sufficient to trigger a treatment order. Before a decision on referral can be made, it must also be shown that medical treatment is likely to alleviate the person's condition or prevent it from getting worse. And secondly, the 1983 Act can be used to make an involuntary commitment for psychopathic disorder at civil law (subject to the satisfaction of treatment conditions) to people of any age, not just those under 21 as was the case under the 1959 Act.

Curability of psychopathic disorder

Despite the positive aspect of including the criterion of 'treatability' in the admission criteria, there is currently no agreement among psychiatrists as to what is and is not treatable. This is well illustrated by the Sore Review of the views of all forensic psychiatrists in England, Scotland and Wales. In this review, consultant forensic psychiatrists answered questions on three case reports that could be classed as psychopathic disorder. There was the least agreement on Case A (a schizoid male, possibly pre-psychotic): 27% of psychiatrists thought it was incurable and 73% thought it treatable. There was the greatest agreement on Case B (a woman with borderline personality disorder): 5% of psychiatrists thought it was incurable and 95% thought it was treatable. In 1993, the results of this review were reviewed by the Department of Health and Home Office Working Party on Psychopathic Disorder, chaired by Dr John Reid.

Despite this lack of consent, patients are admitted and treated under the category of psychopathic disorder. When considering admission under the Mental Health Act, it is probably best to think of treatability as a perfection, which is notoriously a matter of opinion. It would be wrong to declare a person treatable and admit them if you do not have adequate services to provide treatment. So, for example, if treatment requires years and a lot of psychotherapy, and your service can only provide short admissions and some psychotherapy, then the person in that service is incurable. Special NHS orders allow treatment to be provided in another area (additional contract referrals), but this raises ethical issues about how far to refer a patient if there are no adequate services in the area.

Segregation from the community on the grounds of psychopathic disorder involves a consideration of treatability on admission but not on discharge, that is, a patient who has become incurable cannot be discharged on this ground unless there is a tribunal decision that there is no likelihood of treatability if the patient continues to be segregated. This was clearly demonstrated in a case before the Canon Park Mental Health Tribunal in which an inpatient at one stage during her admission refused to accept the only treatment thought likely to help her, psychotherapy. The patient's defence argued that since the patient was now incurable (because there was no other treatment available to her if she refused to cooperate with psychotherapy), she should be discharged (despite her dangerousness and the fact that she was being held in a high-security unit). The tribunal refused to discharge the patient. The patient applied for review to the County Court (part of the Court of Appeal), which quashed the tribunal's decision, which meant the patient was discharged. In conclusion, LJ Mann of the County Court said: "I am nevertheless satisfied that on the grounds given by J Sedley and given effect by Parliament, an incurable psychopath, however dangerous, is not liable to isolation."

This decision raised serious concerns: with many highly dangerous 'incurable' psychopaths currently being held in high security hospitals, should they all now be released? The tribunal appealed and the decision was subsequently overturned by the full Court of Appeal. The Court of Appeal noted that the wording of the Mental Health Act was such that even if a 'curability test' was applied at the admission stage, it was not necessarily relevant when considering whether to continue to hold a patient in hospital. At that stage the tribunal must consider the appropriateness of continuing to hold the patient in hospital, i.e. apply the 'appropriateness test'. Therefore, if a person who is currently refusing treatment or has otherwise become incurable is considered likely to become curable during a subsequent stay in hospital, then continued admission is lawful and appropriate. The Canon Park decision was revisited in another case, but the essential position of the tribunal remains unchanged.

Primary and secondary "psychopaths"

In the past, practitioners divided antisocial personalities into primary and secondary (neurotic) psychopaths. This distinction is no longer found in either the ICD-10 or the DSM-IV, but many psychiatrists still find the concept useful. The primary psychopath syndrome was described by Cleckley. At first glance, these individuals appear normal, charming, intelligent, and easy to get along with without being overly shy. However, if you look into their history, you will find highly egocentric, impulsive, and bizarre behavior that ultimately runs counter to the individual’s interests. There may be no run-ins with law enforcement for an indefinite period of time because these individuals are so quick-witted and charming, and they may achieve high social status before their true colors emerge. Sometimes such a person will tell you a story of early psychological trauma, because that is what psychiatrists are usually interested in, but subsequent investigation does not confirm this information. Their behavior is incomprehensible from the perspective of conventional psychology. Cleckley argued that such psychopaths had an innate disorder of brain function, resulting in a dissociation of emotions (such as guilt) from words. For this reason, Cleckley considered primary psychopaths to be virtually incurable. The concept of primary psychopathy is widely used in some research and psychiatric settings, but has not received much support from clinicians in England. Secondary psychopaths are described as antisocial individuals with severe anxiety. Their personality is largely understood in light of the psychological trauma they experienced early in life. The clinical manifestations of secondary psychopathy are usually more pronounced, with poorer coping skills and frequent self-harm.

Psychopathic disorder and psychotic symptoms

Brief episodes of psychotic symptoms are quite common in prisons and high-security hospitals among individuals classified as psychopathic. They occur in virtually all severe personality disorders, usually during times of stress, but sometimes without any apparent cause. Omet studied 72 women with borderline personality disorder in a special hospital. He described a cyclical pattern of affective disturbance (often similar to endogenous) characterized by anxiety, anger, depression, and tension. After these symptoms have increased (over a period of hours or days), they develop a compulsion to act out externally in the form of criminal (e.g., arson) or self-destructive behavior. The act out is followed by temporary relief of symptoms. The cycle then repeats.

The management of such periods can be difficult, since these states are difficult to bring into a controlled manner. Psychotic periods are usually characterized by a paranoid state with delusions and hallucinations. The subject may react to psychotic experiences with tension, hostility, and destructiveness, as, for example, in an affective disorder. The difficulties of managing cases are the same, although antipsychotic drug therapy usually produces a fairly rapid effect. Some of these individuals become more stable if they take antipsychotics continuously. In this case, relatively low doses may be sufficient.

Psychopathic disorder, mental illness and substance abuse

Psychiatrists often see people with a long history of disruptive behaviour and personality difficulties, including poor impulse control, repeated and deliberate self-harm, violence against property and violence towards others. Often these people also abuse drugs and have episodes that closely resemble psychotic episodes. They can present significant challenges both in terms of arranging for them to receive the care they need and in terms of diagnosis, as they are too disorganised to be admitted to a regular psychiatric unit. They commonly drift between mental health services and the criminal justice system, but may also become homeless. There are no easy answers to how to help these people, short of admitting them to a high-security unit. Such admissions often take place via a prison or police station. Often, forensic psychiatrists will find that such patients, who are kept in a structured environment and under intense supervision, have a psychotic illness with underlying personality problems. Long-term hospitalization can often result in significant functional improvement in such a patient.

Treatment of psychopathic disorder

The treatment of adults with psychopathic disorder is considered in great detail in a review by Dolan and Coid, part of a study commissioned by the Department of Health and the Home Office. The resulting document was called A Review of Health and Social Care Services for Mentally Disordered Offenders and Others with Similar Service Needs, led by Dr John Reed. The review was prompted by a lack of consensus on the best treatment approach and whether these patients are curable. Here are some statements that reflect the limitations of our knowledge on the treatment of ‘psychopathic disorder’:

• "There is, of course, no evidence to support or indicate that psychiatry has succeeded in finding a therapy that cures or profoundly changes the psychopath" (Cleckley, 1964)
• “When looking through the literature on the treatment of personality disorders, one is struck by how little we know about these conditions” (Frosch, 1983)
• "The treatment literature for antisocial personality disorder is grossly inadequate" (Quality Assurance Project, 1991)
• "In reviewing the scientific literature on the treatment of psychopathy, two things are inescapably striking: first, that the scientific studies of treatment outcome in psychopathy are very few and of poor quality; and second, and more worryingly, that despite decades of review and commentary on these studies, no clear advances have been made to date" (Dolan and Coid, 1993)

Age aspect

Before considering the treatment of psychopathy, it is important to recognize the natural history of the personality disorders found in the "psychopath." There are no clear, consistent answers based on scientific research, but it is generally accepted that certain personality disorders improve somewhat with age in some individuals - particularly borderline, antisocial, and histrionic personality disorders. Other disorders are more persistent. These include paranoid, obsessive-compulsive, schizoid, avoidant, dependent, and passive-aggressive personality disorders. In those cases that improve with time, changes begin to be seen after middle age.

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Treatment of psychopathic disorder in prison

Prisons in many countries have tried for many years to use a variety of approaches to reform or rehabilitate repeat offenders, using religious instruction, education, work ethic, punitive methods, etc. Typical psychiatric approaches are as follows:

Herstedvester Health Centre, Denmark

Opened in the 1930s, the centre was the first prison to attempt to treat psychopaths using psychotherapy. It was run by psychiatrist Dr Sturrup and was run on the principles of a therapeutic community. Initially, the emphasis was on the perpetuity of the sentences to motivate prisoners to participate in activities, meaning that by participating in the programmes, prisoners could earn their release by achieving appropriate improvement. The prison claims to have achieved long-term improvements in its clients. However, a comparative study described in the Butler Commission report found no difference in the final recidivism rates of former Herstedwester prisoners compared to similar prisoners in a regular prison, although they did show marked improvements during treatment.

Grendon Underwood Prison, England

This was a 200-bed prison, planned in the 1930s and established in 1964 on the hypothesis that criminality might be the result of a neurosis which could in turn be cured. In practice, the prison was used to treat, through group therapy, those offenders with personality disorders who could work profitably in a group and who were already serving a prison sentence. Prisoners were referred to Grendon by the prison medical service after their sentence had been determined. Final selection was made on site by Grendon staff, on the basis of the prisoner's intellectual level, his ability to express himself verbally, his ability and willingness to work in groups and evidence of some personal achievement. The regime at Grendon between 1987 and 1994 is described in detail in Genders & Player. Gunn showed that the attitudes and behaviour of Grendon prisoners were improved compared with those of prisoners in other prisons, but that the beneficial effects of the Grendon regime on return to the community were countered by the harsh realities of the environment. It was found that incidental factors in the community (eg employment, marriage) were as important in the long run as the overall Grendon experience. Overall, after ten years in the community, Grendon ex-prisoners had similar recidivism rates to an equivalent group from a mainstream prison, although more motivated and intellectually advanced individuals might benefit more. Cullen's study followed 244 fixed-sentence prisoners for more than two years after release from prison. It found that those prisoners who had been in Grendon for less than 18 months had a recidivism rate of 40%, while those who had been in Grendon for more than 18 months had a recidivism rate of 20%.

It should be noted that the prison population changed between the Gunn and Cullen studies. During the Gunn study, there was a higher percentage of young people serving shorter sentences for acquisitive crimes.

Wing C, Parkhurst Prison, England

This wing, which closed in 1995, was designed for men with personality disorders associated with high levels of stress, emotional lability, violence and behavioural problems (self-harm, impulsivity, disruptive behaviour to relieve stress). Such men were unable to cope with the normal prison regime and were too disorganised (too impulsive or aggressive) to expect to succeed in Grendon. The existing regime helped these highly disturbed prisoners to serve their sentences. It achieved this by providing greater flexibility and more attention to prisoners (drug therapy and psychological counselling) than in a normal prison. The overall clinical impression was of a significant reduction in violent and disruptive incidents while prisoners were in this wing. There were no studies of the long-term effects of the service. A study of a similar unit at Barlinnie Prison in Scotland (now closed) noted a rapid reduction in violent behaviour in the unit and indicated a reduction in subsequent recidivism.

Treatment of psychopathic disorder in hospital

Regular hospital

Mainstream hospitals admit patients with personality disorders during crises, that is, periods of depression, high anxiety, or psychosis, and this may be useful in preventing harm to themselves or others. However, most feel that they cannot treat such patients on a long-term basis because of their persistent, disruptive, and authority-defying behavior, which they are unable to change. This may reflect a general decline in the number of hospitalization orders issued by the courts for people with psychopathic disorder in recent years.

Special hospital

In recent years, the rate of admission of patients with psychopathic disorder to the special hospital has declined, from about 60 per year in 1986-1990 to 40 per year in 1991-1996. This is less than one in every 2,000 people convicted of violent or sexual offences. Treatment of psychopathic disorder at Broadmoor involves psychotherapy, education and rehabilitation in a highly controlled environment. Treating such patients in a highly secure environment is a very drawn-out process, and often leaves patients temporarily or permanently incurable. These "incurable psychopaths" can play a very negative role, disrupting other patients in the unit and the hospital as a whole.

High security departments

Of the patients admitted to the regional maximum security units, only a very small proportion have a psychopathic disorder as their primary diagnosis. Most of these patients are transferred from special hospitals - as an attempt to rehabilitate the patient in the community. Very few come directly from the courts, prisons and the community. The treatment approach is the same as in the special hospital. Additional attention and increased supervision seem to be effective in reducing the level of behavioral problems, at least in the institution itself.

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Henderson Hospital, England

Based at Belmont Hospital in Sutton, this unit was set up in 1947 to treat patients with 'psychopathic disorder' within the NHS. It works best with articulate, intelligent and fairly young psychopaths without a significant criminal or violent history. The unit is renowned for its therapeutic community approach, developed under the guidance of Maxwell Jones. Henderson Hospital only accepts voluntary patients. It has 29 beds and around half of its residents have criminal convictions. Available research suggests that Henderson Hospital currently has the best results for patients with 'psychopathic disorder', although it has very high admission criteria.

Clinic Van der Hoeven, Utrecht, Holland

This is one of several well-known Dutch clinics run by psychiatrists that treat criminals with psychopathic disorders. The private clinic Van der Hoeven is a therapeutic community (housed in a secure building) that uses group psychotherapy combined with educational programs for rehabilitation and resocialization. This is complemented by a good system of “parole”. Prisoners are held at the clinic for about two years. Although the clinic claims success in producing both short-term and long-term changes in its clients, these claims have not yet been confirmed in controlled studies.

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Organization of stay in probation service hostels

Probation service hostels differ in their ability to improve the behavior of probationers during their stay in the hostel. The study showed that the most effective hostels were those with an atmosphere of attention to its residents, although with the preservation of a strict schedule. The least effective were hostels with an atmosphere of permissiveness or indifference and lack of interest in the hostel residents. Unfortunately, the successes noted in the behavior of probationers during their stay in the hostel do not persist after leaving for the community. After two to three years, the recidivism rate was the same, regardless of the characteristics of the hostel.

Individual psychotherapy in the community

The most famous work in this area is the Cambridge-Somerville study, which began in the United States. It was an attempt to see how individual psychological counseling could prevent the development of antisocial personality in young people at risk. The experiment compared treated and untreated groups. It was assumed that young people in the treatment group would have to meet with the same counselor on a voluntary basis every week. Unfortunately, the experiment was interrupted by World War II, and the counselors were drafted into the army. Overall, it can be said that people who received psychological counseling were no better than those who did not.

Other individual clinical approaches

The issues of psychotherapy for individuals with borderline and narcissistic personality disorders are covered in the review. The main conclusion from this study is the need for long-term commitment to treatment. Proponents of each method claim success, but, nevertheless, without comparative trials, it remains unclear which approach will be effective in each specific case.

Reality Therapy

This is an attempt to teach delinquents practical social skills - how to solve real problems that exist today.

Supportive psychological counseling

This is the mainstay of probation and outpatient services. Firmness, tactfully combined with psychological acceptance and warmth, is probably the most effective approach, although there is no evidence that this approach can produce lasting change in clients. Clinically, it helps them stay out of trouble while they are involved in a counselling and support programme.

Dynamic psychotherapy

Many anecdotal reports of success with dynamic psychotherapy have been made, but consistent evidence for its use is lacking. In principle, dynamic psychotherapy cannot be used with patients suffering from antisocial personality disorder, although some success has been reported in inpatient settings. In general, dynamic psychotherapy is unsuitable for treating patients isolated from society because of a psychopathic disorder.

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Family therapy

This type of intervention will expose family dynamics and appears to be a very powerful tool. There are no empirical studies on the effectiveness of this method in offenders with personality disorders.

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Group therapy

Group work can be very helpful and is commonly used in institutions that house people with personality disorders. Cognitive therapy

Among individuals with anger and violence problems, some success has been reported with psychological therapy based on automatic thought recognition combined with relaxation, and cognitive and behavior modification techniques. In particular, some success has been reported in changing violent behavior, at least in the short term. This therapeutic approach may help in treating some specific aspects of behavior or attitude in individual patients. The selection criteria are the same as for psychotherapy in "nonpsychopathic" individuals.

Physical Therapy Methods

There have been attempts to treat "psychopaths" with electroshock therapy and psychosurgery. However, there is no reliable evidence of the effectiveness of either method for this group of patients.

Drug treatment of psychopathic disorder

Personality disorders cannot be cured by drugs, but drugs may be of some help, particularly for those with severe symptoms of tension and anxiety. Patients with borderline personality disorder are most likely to benefit from careful use of drugs. Drug therapy appears to be helpful for those with schizotypal personality disorder and for some personality disorders involving loss of control over one's own behaviour. A very detailed review of the effects of drug therapy on people included in the category of psychopathic disorder was prepared by Dr Bridget Dolan and Dr Jeremy Coid for the report of the Psychopathic Disorder Working Group, chaired by Dr Reid. Dolan and Coid published their findings in a book published in 1993. These findings are included in the summary below.

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Benzodiazepines

The existing literature on the effects of benzodiazepines on behavior and personality disorders is not of high quality. However, clinical experience suggests that benzodiazepines may be useful in acute situations of loss of control and severe behavioral disturbances on the part of the patient, or for short-term use during periods of anxiety and tension. However, caution is needed, as some people have reported disinhibition and rage reactions to benzodiazepines. In general, these drugs should not be used to treat personality disorders, particularly because of their high addictive potential.

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Antidepressants

Depression is an integral part of many personality disorders, and it usually fluctuates, regardless of the use of antidepressants. There are currently no adequately conducted studies that would prove that the improvement in patients with antidepressants occurs precisely as a result of the pharmacological action of the drug, and is not just a natural change in the existing condition. At the same time, patients with personality disorders can develop very severe depression, and in severe depression it is important to use antidepressants. Persistent dysphoria and atypical depression in borderline personality disorder can respond to MAO inhibitors. However, given the potential danger of the side effects of these drugs and the unreliability of patients suffering from severe personality disorders, MAO inhibitors may be appropriate only after unsuccessful attempts to use lithium and carbamazepine.

Maintenance therapy with lithium appears to be a promising approach to the treatment of personality disorders. Lithium is particularly indicated for patients with personality disorders characterized by impulsivity, mood instability, or unintentional aggressive outbursts.

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Large tranquilizers

Any of the major tranquilizers can be used to reduce persistent tension - sometimes they work even in relatively low doses (e.g. flupentixol 20 mg per month or less), but during periods of high tension higher doses may be needed. Low-dose therapy may be particularly effective for patients with schizotypal features, as well as for those whose psychopathic disorder occurs with recurrent brief episodes. Neuroleptics also help some patients with borderline personality disorder with self-harming manifestations, aggressive outbursts and periods of anxiety and depersonalization.

Stimulants

It has long been noted that amphetamines can reduce tension in some psychopaths, but the danger of drug abuse and addiction generally outweighs the potential benefits of amphetamine use. There is considerable interest in the use of amphetamine mixtures in adults who had persistent attention deficit hyperactivity disorder in childhood. Many such adults in the United States are prescribed amphetamine derivatives, with proven benefit. However, there is still considerable skepticism in the United Kingdom, and such prescriptions are very rare.

Anticonvulsants

Carbamazepine has been shown to help with hyperactivity, aggression, and poor impulse control. This effect is not limited to any particular personality disorder. Rather, it is symptom-specific, and therefore such therapy is best used against the symptom rather than against a diagnosis of a specific personality disorder.

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Medical and legal aspects of psychopathic disorder

One important legal issue that arises with psychopathic disorder is the possibility of institutionalization versus community care sentences or imprisonment. Occasionally, a defense of diminished responsibility is allowed in murder cases, but such cases are rare. Psychopathic disorder does not lead to a finding of incompetence or insanity. If no recommendation is made for institutionalization, the finding of psychopathic disorder can be a double-edged sword for the defendant: on the one hand, it may be interpreted as a mitigating factor at sentencing, but on the other hand, a judge weighing the sentence for an "incurable psychopath" may impose a longer than usual period of imprisonment in order to protect society.

For many years now, psychiatrists have been very cautious about recommending hospital treatment for “psychopaths”. This is largely due to a lack of confidence in the curability of the disorder, as well as a lack of necessary resources and the negative experience of accepting a patient for treatment only to find out that he or she is incurable. Having accepted a patient who turns out to be or subsequently becomes incurable, the psychiatrist risks being faced with a dilemma: increasing pressure to discharge the person who is dangerous to society, on the one hand, or switching to “preventive” long-term detention in hospital (“preventive” in this case means preventing harm to society, i.e. psychiatric care turns into detention). The latter option is especially likely if the patient hospitalized under Section 37/41 of the Mental Health Act is found to be or becomes incurable, since in such cases the Home Office and the Mental Health Tribunal are extremely reluctant to grant permission for discharge. To avoid similar problems in the future, the report of the Group led by Dr Reed made some recommendations that have now been implemented into practice and legislation.

Two approaches have been proposed to help address the problem of more accurately determining treatability. Firstly, the Reed Report recommended that treatment decisions should only be made on the basis of a multidisciplinary assessment. In the past, decisions were sometimes taken by doctors alone, although good assessment now rightly involves other disciplines. Secondly, the Crimes (Sentences) Act 1997 amended section 38 of the Mental Health Act 1983. A temporary hospitalisation order of up to 12 months can now be used, thus allowing a longer period of time for assessment and trial of treatment options before final recommendations are made to the court.

Once treatability has been established, a whole range of new sentencing options opens up. The Crimes (Sentencing) Act 1997 added sections 45A and 45B to the Mental Health Act. These sections give the Crown Court the power, when imposing a prison sentence on an accused with a psychopathic disorder, to add to that sentence a hospital referral. In effect, the following options now exist: if a psychiatrist is satisfied that a 'psychopathic' offender is treatable, then the court may recommend that the person be admitted to hospital under sections 37 and 37/41 of the Mental Health Act 1983. If, however, the psychiatrist considers the offender to be incurable, no hospital referral will be made (although there may be an informal return to the issue after sentencing and a reconsideration of the possibility of hospitalisation under section 49/49 of the Mental Health Act 1983). The new s45A ‘hospital commitment order’ (known in the profession as a ‘hybrid order’) is only used where a psychiatrist can say that the offender is likely to be treatable. A hybrid order requires a doctor to recommend to the court the use of a hospital commitment order (s37) and the judge can then decide on a ‘hybrid order’ if he so wishes (a doctor can only recommend a hospital commitment order, not a hybrid order as such). The idea is that the defendant will be admitted to hospital and also receive a fixed or indefinite sentence at the same time. The defendant will then begin their sentence in hospital and may eventually be discharged into the community directly from hospital. However, if the defendant becomes incurable or completes treatment before the end of their sentence, they may be transferred to prison to serve the remainder of their sentence and subsequently released from prison. This new power is currently being reviewed by mental health services and the Home Office. No decisions were made to implement hybrid orders between October 1997, when the order was enacted, and September 1998.