- 1.1 General principles for working with people with antisocial personality disorder
- 1.2 Prevention of antisocial personality disorder – working with children and young people and their families
- 1.3 Assessment and risk management of antisocial personality disorder
- 1.4 Treatment and management of antisocial personality disorder and related and comorbid disorders
- 1.5 Psychopathy and dangerous and severe personality disorder
- 1.6 Organisation and planning of services
- Terms used in this guideline
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
In March 2013, recommendations 188.8.131.52, 184.108.40.206, 220.127.116.11, 18.104.22.168, 22.214.171.124, 126.96.36.199, 188.8.131.52 to 184.108.40.206, 220.127.116.11, 18.104.22.168, 22.214.171.124 to 126.96.36.199 and 188.8.131.52 to 184.108.40.206 were deleted and replaced by the NICE guideline on antisocial behaviour and conduct disorders in children and young people.
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
People with psychopathy and people who meet criteria for dangerous and severe personality disorder (DSPD) represent a small proportion of people with antisocial personality disorder. However, they present a very high risk of harm to others and consume a significant proportion of the services for people with antisocial personality disorder. In the absence of any high-quality evidence for the treatment of DSPD, the Guideline Development Group drew on the evidence for the treatment of antisocial personality disorder to arrive at their recommendations. Interventions will often need to be adapted for DSPD (for example, a significant extension of the duration of the intervention). People with DSPD can be seen as having a lifelong disability that requires continued input and support over many years.
220.127.116.11 For people in community and institutional settings who meet criteria for psychopathy or DSPD, consider cognitive and behavioural interventions (for example, programmes such as 'reasoning and rehabilitation') focused on reducing offending and other antisocial behaviour. These interventions should be adapted for this group by extending the nature (for example, concurrent individual and group sessions) and duration of the intervention, and by providing booster sessions, continued follow-up and close monitoring.
18.104.22.168 For people who meet criteria for psychopathy or DSPD, offer treatment for any comorbid disorders in line with existing NICE guidance (see the NICE topic page on mental health and behavioural conditions). This should happen regardless of whether the person is receiving treatment for psychopathy or DSPD because effective treatment of comorbid disorders may reduce the risk associated with psychopathy or DSPD.
There has been a considerable expansion of services for people with antisocial personality disorder in recent years involving a wider range of agencies in the health and social care sector, the non-statutory sector and the criminal justice system. If the full benefit of these additional services is to be realised, effective care pathways and specialist networks need to be developed.
22.214.171.124 Provision of services for people with antisocial personality disorder often involves significant inter-agency working. Therefore, services should ensure that there are clear pathways for people with antisocial personality disorder so that the most effective multi-agency care is provided. These pathways should:
specify the various interventions that are available at each point
enable effective communication among clinicians and organisations at all points and provide the means to resolve differences and disagreements.
Clearly agreed local criteria should also be established to facilitate the transfer of people with antisocial personality disorder between services. As far as is possible, shared objective criteria should be developed relating to comprehensive assessment of need and risk.
126.96.36.199 Services should consider establishing antisocial personality disorder networks, where possible linked to other personality disorder networks. (They may be organised at the level of primary care trusts, local authorities, strategic health authorities or government offices.) These networks should be multi-agency, should actively involve people with antisocial personality disorder and should:
take a significant role in training staff, including those in primary care, general, secondary and forensic mental health services, and in the criminal justice system
have resources to provide specialist support and supervision for staff
take a central role in the development of standards for and the coordination of clinical pathways
monitor the effective operation of clinical pathways.
188.8.131.52 Healthcare professionals should normally only consider admitting people with antisocial personality disorder to inpatient services for crisis management or for the treatment of comorbid disorders. Admission should be brief, where possible set out in a previously agreed crisis plan and have a defined purpose and end point.
184.108.40.206 Admission to inpatient services solely for the treatment of antisocial personality disorder or its associated risks is likely to be a lengthy process and should:
be under the care of forensic/specialist personality disorder services
not usually be under a hospital order under a section of the Mental Health Act (in the rare instance that this is done, seek advice from a forensic/specialist personality service).
Working in services for people with antisocial personality disorder presents a considerable challenge for staff. Effective training and support is crucial so that staff can adhere to the specified treatment programme and manage any emotional pressures arising from their work.
220.127.116.11 All staff working with people with antisocial personality disorder should be familiar with the Department of Health's Ten essential shared capabilities: a framework for the whole of the mental health workforce, and have a knowledge and awareness of antisocial personality disorder that facilitates effective working with service users, families or carers, and colleagues.
18.104.22.168 All staff working with people with antisocial personality disorder should have skills appropriate to the nature and level of contact with service users. These skills include:
for all frontline staff, knowledge about antisocial personality disorder and understanding behaviours in context, including awareness of the potential for therapeutic boundary violations (for example, inappropriate relations with service users)
for staff with regular and sustained contact with people with antisocial personality disorder, the ability to respond effectively to the needs of service users
for staff with direct therapeutic or management roles, competence in the specific treatment interventions and management strategies used in the service.
22.214.171.124 Services should ensure that all staff providing psychosocial or pharmacological interventions for the treatment or prevention of antisocial personality disorder are competent and properly qualified and supervised, and that they adhere closely to the structure and duration of the interventions as set out in the relevant treatment manuals. This should be achieved through:
use of competence frameworks based on relevant treatment manuals
routine use of sessional outcome measures
routine direct monitoring and evaluation of staff adherence, for example through the use of video and audio tapes and external audit and scrutiny where appropriate.
Supervision and support
126.96.36.199 Services should ensure that staff supervision is built into the routine working of the service, is properly resourced within local systems and is monitored. Supervision, which may be provided by staff external to the service, should:
make use of direct observation (for example, recordings of sessions) and routine outcome measures
support adherence to the specific intervention
promote general therapeutic consistency and reliability
counter negative attitudes among staff.
188.8.131.52 Forensic services should ensure that systems for all staff working with people with antisocial personality disorder are in place that provide:
comprehensive induction programmes in which the purpose of the service is made clear
a supportive and open environment that encourages reflective practice and honesty about individual difficulties such as the potential for therapeutic boundary violations (such as inappropriate relations with service users)
continuing staff support to review and explore the ethical and clinical challenges involved in working in high-intensity environments, thereby building staff capacity and resilience.
Usually offered to children who are aggressive at school, anger control includes a number of cognitive and behavioural techniques similar to cognitive problem-solving skills training (see below). It also includes training of other skills such as relaxation and social skills.
An intervention that is systemic in focus and is influenced by other approaches. The main elements include engaging and supporting the family, identifying maladaptive family interactions and seeking to promote new and more adaptive family interactions.
An intervention that aims to reduce children's conduct problems by teaching them different responses to interpersonal situations. Using cognitive and behavioural techniques with the child, the training has a focus on thought processes. The training includes:
teaching a step-by-step approach to solving interpersonal problems
structured tasks such as games and stories to aid the development of skills
combining a variety of approaches including modelling and practice, role-playing and reinforcement.
A family-based intervention that is behavioural in focus. The main elements include engagement and motivation of the family in treatment, problem-solving and behaviour change through parent-training and communication-training, and seeking to generalise change from specific behaviours to positively influence interactions both within the family and with community agencies such as schools.
Using strategies from family therapy and behaviour therapy to intervene directly in systems and processes related to antisocial behaviour (for example, parental discipline, family affective relations, peer associations and school performances) for children or young people in foster care and other out-of-home placements. This includes group meetings and other support for the foster parents and family therapy with the child's biological parents.
Using strategies from family therapy and behaviour therapy to intervene directly in systems and processes related to antisocial behaviour (for example, parental discipline, family affective relations, peer associations and school performances) for children or young people.
An intervention that aims to teach the principles of child behaviour management, to increase parental competence and confidence in raising children and to improve the parent/carer–child relationship by using good communication and positive attention to aid the child's development. Examples of well-developed programmes are the Triple P (Sanders et al. 2000) and Webster-Stratton (Webster-Stratton et al. 1988).