The Association of Therapeutic Communities is a small multidisciplinary professional and charitable organisation which promotes the understanding and implementation of the therapeutic community as a treatment method, and supports people either working in established therapeutic communities, or in the process of developing new therapeutic communities. Therapeutic communities are treatment programmes for people with various severe mental health problems, which include personality disorders, in a variety of settings, which include prisons, NHS hospital and day units, special schools, probation and social services, and rehabilitation hostels in the voluntary sector.
Therapeutic communities are small cohesive communities where members (whether resident or day) have a significant involvement in decision making and the practicalities of running the unit. Based on ideas of collective responsibility, citizenship and empowerment, therapeutic communities are deliberately structured in a way that aims to encourage responsibility and avoid unhelpful dependency on professionals. Members are seen as bringing strengths and creative energy into the therapeutic setting, and the peer group is seen as all important in establishing a strong therapeutic alliance. The flattened hierarchy and delegated decision making is sometimes misunderstood as anarchy by outside. However, staff in modern therapeutic communities are deeply aware of the need for strong leadership and their responsibility to provide a safe ‘frame’ for therapeutic work.
Some therapeutic communities work exclusively in a group forum, whether intensive large group sociotherapy and psychotherapy or small group psychotherapy, while some incorporate individual psychotherapy into the structure. The day to day experience of living and working together, or social therapy, is considered as important an aspect of the treatment as formal therapy, and the structure is such that the two are closely integrated and inform each other. Understanding the institutional dynamics of the social setting is fundamental. This understanding is informed by systems theory and organisational management theory as well as psychoanalytic and group analytic ideas. Some therapeutic communities also integrate other forms of group therapy, such as cognitive behavioural therapy, into their treatment programmes.
An important underlying principle is that all involved are encouraged to be curious about themselves, each other, the staff, the management structure, psychological process, the group process, the institution and everything else pertinent to events and relationship within the community. This is known as the ‘culture of enquiry’ - an openness to questioning so that understanding is owned by all and not seen solely to reside in professionals. The structured attempt to raise the status of members and the all embracing ‘culture of enquiry’ mean that therapeutic communities, whilst differing in detail between themselves, have a cohesive philosophy and aspire to be more than a setting where severely disturbed individuals can be contained whilst they undergo therapy. In addition, and related to this philosophy, staff in therapeutic communities receive day-to-day, on the job supervision of their work, in addition to other more formal supervision sessions.
Therapeutic communities are increasingly being used for the treatment of people with personality disorders, although it is usual at the present time to refer to such people using therapeutic communities as suffering from severe personality disorders (Norton & Hinshelwood, 1996). Many of these people meet the diagnostic criteria for borderline personality disorder (American Psychiatric Association, 1994, Diagnostic and Statistical Manual of Mental Disorders, 4th edition). However, service users do not appreciate this label and many professionals also recognise the stigmatising message it conveys. It can be seen as the most recent in a history of pejorative labels used for this client group. Where possible, straight forward descriptions such as ‘emotionally unstable’; ‘chaotic’ or ‘disorganised attachment’ are less stigmatising than broad diagnostic categories. One of the reasons users dislike the term SPD is that it is over inclusive.
It encompasses people with severe dis-social personality disorder, often characterised in the media as sadistic murderers, whom most psychiatrists with their present state of knowledge would consider untreatable; people who fit the criteria for emotionally unstable personality disorder (ICD10) or borderline personality disorder, particularly those with an extensive history of self-harm; those with diffuse personality disorder who fulfil the criteria for a number of different personality disorders using the Personality Assessment Schedule; and those severely disabled by their personality but without a history of harm to themselves or others e.g. people with severe obsessive compulsive disorder.
People currently found in therapeutic communities might have dis-social traits and often have a forensic history, but do not usually fulfil the criteria for dis-social personality disorder. These people have profound problems of living and relating, together with long-standing, persistent, deeply rooted emotional difficulties, usually leading to impulsive high risk and self destructive behaviours. One of the characteristics of these people is that they evoke high levels of anxiety in carers, relatives and professionals, and tend to have relatively frequent, often escalating, contact across a spectrum of services including mental health, social services, accident and emergency, general practitioners and the legal and penal systems. The long-term prognosis for many of these people is relatively good, particularly if they can access appropriately focused services. Therapeutic communities are effective in managing self-destructive and acting-out behaviour, and at maintaining and managing boundaries. They also have clear and consistent rules, and responsibility for the management and maintenance of the rules is shared by the community as a whole, and not just the staff.
This policy document recognises that therapeutic communities, such as HMP Grendon and Henderson Hospital, have been shown to be clinically and cost effective in the management of a subgroup of those with personality disorder (Annex C, p.37), and we understand HMP Grendon has made a separate submission to you, elaborating on this. However, the evidence is more extensive than that. There is accumulating evidence, albeit some of it at a low level of research, of the effectiveness and particular suitability of treatment in a therapeutic community for people with personality disorders, and particularly severe personality disorders, and that therapeutic communities are the only treatment that works with some personality disorders.
Recently, an NHS systematic literature review of the international research on the effectiveness of therapeutic communities in treating people with personality disorders and mentally disordered offenders in secure and non-secure, psychiatric and other settings, commissioned by the then High Security Psychiatric Services Commissioning Board, was undertaken by Jan Lees, Barbara Rawlings and Nick Manning (Lees et al, 1999). This is one of the reviews referred to in the policy document in Annex D, p.40, point 10, which is now published by the NHS Centre for Reviews and Dissemination at the University of York (October, 1999).
This review focused on research literature relating to the democratic therapeutic community, but also included concept-based therapeutic communities, primarily for substance abusers, in secure settings. The review overviewed a whole range of literature, but the review concentrates on the post-treatment outcome findings. The study began with 8,160 articles and other literature, reduced to 294 broadly covering the relevant area. For post-treatment outcome findings, there were 10 randomised controlled trials, 10 cross-institutional, cross-treatment or comparative studies, and a further 32 studies using some kind of control or comparison group. This review took the latter as the minimum level of rigour that is acceptable, which left a total of 52 acceptable studies, all of which are discussed in some detail in the review. Of these 52, 41 relate to democratic therapeutic communities, and 11 to concept-based therapeutic communities.
Although many of the findings are presented in narrative form, the authors have conducted a systematic meta-analysis of some of the studies, using odds ratios. Because of the quality of data presented, and the quality of the analyses of this data in the studies, the authors of this review were only able to meta-analyse 29 studies in total, dated between 1960 and 1998, and including 8 of the RCTs. Where there was a choice of outcome measures and control groups, emphasis was placed on conservative criteria, such as reconviction rates rather than psychological improvements, and on non-treated controls. This odds-ratio summary is on page 5 of the Briefing Paper, (which is included with this response), with 19 of the 29 studies indicating a positive effect, within the 95% level of confidence.
Finally, with the publication of this systematic literature review, therapeutic communities now have Type I evidence, according to the new National Service Framework for Mental Health - in other words, they have at least one good systematic review, including at least one RCT.
In addition, there is meta-analytical and clinical evidence that therapeutic communities produce changes in people’s mental health and functioning, for example, Dolan et al’s study of Henderson Hospital patients with personality disorder showed that treatment in a therapeutic community produced an improvement in the symptoms of borderline personality disorder (Dolan et al, 1997). Also, there are cost offset studies by Dolan et al (1996), relating to Henderson Hospital; Chiesa et al (1996), relating to the Cassel Hospital; and Davies et al (1997), relating to Francis Dixon Lodge Therapeutic Community, and all three of these therapeutic communities treating people with personality disorders showed a reduction in service consumption and costs.
There is also evidence from this NHS review of the efficacy of therapeutic communities, modified for prison security needs, in managing difficult prisoners, and significantly reducing serious prison discipline incidents after admission, including fire setting, violence, self-harm and absconding. There is also evidence that therapeutic communities in secure settings are effective for offenders (Marshall, 1997; Cullen, 1993). In addition Tim Newell, the Governor of Grendon has stated that the therapeutic communities in Grendon, Wormwood Scrubs and Gartree have been shown to have short, medium and long-term effects on reconviction rates as well as more immediate behaviour. The placement of a therapeutic community within a secure environment however poses some problems. There are often conflicts between the need to maintain security and control (which is regarded as the primary task of prisons) and the provision of treatment in a therapeutic community, since therapeutic communities ideally devolve major decisions regarding organisation, rules, treatment, sanctions, admission and discharge, to its members.
The government’s policy document suggests in Annex D, p.40, point 6, that research has indicated that therapeutic community approaches could possibly be counter productive for people with very severe personality disorder who also have high scores on the Hare psychopathy checklist. We assume this refers to Rice et al’s (1992) study of Penetanguishene. This study showed an increase in violent offending for those psychopaths with high Hare scores treated in a therapeutic community environment. The findings are debatable, but suggest relevance for the DSPD proposals.
The findings could be seen as suggesting that people who are very psychopathic are made more dangerous by therapeutic community treatment; or they may mean that those who are very psychopathic who are forced to undergo treatment become more dangerous. Clinical experience would strongly suggest that the latter is the reason for the Penetanguishene results, although it is clear some very psychopathic people are unable to engage or are unsuitable for engagement in therapeutic community treatment programmes.
However, purely from a research point of view, the findings of this study are not conclusive or impressive, for a number of reasons. Methodologically, the study is a retrospective evaluation, using a matched group, quasi-experimental design, which is not the strongest of research designs. More importantly, however, while the regime described appears to have some of the characteristics of a therapeutic community, there are many others which would set it well beyond a claim to be a therapeutic community, for example, entry to and participation in the therapeutic community were not voluntary; stated willingness to participate was not a selection criterion, and people could be assigned to the programme even when they did not wish to go; 80 hours intensive group therapy a week leaves little reflective space; all aspects of patients lives were monitored and structured; patients had very little contact with professional staff; very little effort was expended in organised recreational activities; tight limits were imposed on viewing television, reading material and even on social interaction among patients; non-compliance and disruption were not allowed - this is not a therapeutic community in operation, and most of it runs counter to a culture of enquiry!
This study is included in Lees et al’s (1999) meta-analysis (A19), and its findings are negative, but the authors had to make a very difficult decision about its inclusion. By their criteria, it would probably not have been included in the study at all, as a therapeutic community. However, given the high profile of this study, and because the authors did not want to be seen to bias the findings by excluding a study with such negative findings, they reluctantly included it - had this not been the case, it would not be there.
However, although there is evidence that therapeutic communities work for personality disorder/attachment disorder/emotional instability - however you like to label it, this evidence does not relate specifically to these (very disturbed) dangerous people with severe personality disorders people referred to in this policy document - in other words, therapeutic communities work for people with personality disorders and severe personality disorders, but may or may not work for dangerous people with personality disorders, depending on how these are defined. We need further research to tell us whether they work for this group or not.
The NHS systematic review concludes that future research on the effectiveness of therapeutic communities for personality disorders should include further RCTs (although these have to overcome the problems presented because therapeutic communities control their own intake, and the treatment intervention itself is multidimensional and volatile), but should also include more complex, cross-institutional studies ‘in the field’, together with further cost-offset studies to complement those few already developed. In the light of this, the ATC has applied for, and just received, a research grant from the NCLB to undertake a comparative, cross-institutional evaluation of therapeutic community effectiveness for people with personality disorders, in secure and non-secure settings, including the Personality Disorder Units in the Special Hospitals. This study is using natural variations in the TC field as the basis for the statistical causal modelling, using path analytical structural equations, of the interaction of the treatment processes with outcome change. This study started in September 1999, and is due to complete in August, 2002.
The above is the research context. What about the policy context? The Association of Therapeutic Communities has just produced a new policy document entitled ‘The Need for an NHS Policy on Developing the Role of Therapeutic Communities in the Treatment of ‘Personality Disorder’’ (1999). This document highlights that there is a national and local deficit in services for individuals with borderline personality organisation, and that the optimal treatment is long-term psycho-social intervention with an appropriate level of containment and a consistent but not rigid approach. The document suggests that while many of these people could be helped within general mental health services with appropriate training, supervision and support for staff, and others can be helped by out-patient psychotherapy services, some will need more intensively contained treatment within a therapeutic community, or similar specialised service.
The Association of Therapeutic Communities’ policy document makes a number of conclusions and recommendations. The following are of relevance here. Therapeutic communities offer a valuable service within the NHS, particularly to those with severe borderline personality organisation, who as a group are otherwise poorly resourced, and so existing therapeutic communities should be supported. Service provision is currently patchy and poorly co-ordinated resulting in ‘post-code prescribing’: based on the availability of a local therapeutic community. This strongly suggests that many people with clinical need who could benefit are not referred for treatment, so service provision and referral should be based on clinical need and capacity to benefit. There is concern that the prevalence of people with severe borderline personality organisation may be rising: treatment provision for this client group would be likely to improve if the natural history of the condition was more fully understood; preventative strategies should be developed, and the social policy debate should be informed appropriately.
So what do the new proposals suggest to us?
Therapeutic communities, as well as general psychiatrists and psychotherapists, are reporting seeing more people diagnosed as having severe personality disorder, but therapeutic communities do not know how many of the people with SPD that therapeutic communities see could be defined as dangerous, and in need of containing. For therapeutic communities, the picture is made increasingly complex because of the co-presentation by many of our patients with substance abuse issues. It is also becoming more and more difficult within the NHS to take risks with these patients. Will these proposals mean that we will be unable to work with any element of risk?
Therapeutic communities have some concerns about the proposals. Firstly, dangerous people with severe personality disorder are not clearly defined (indeed they are often conflated in statements in this document with severe personality disorder as a whole). Nationally, there is no agreed definition of severe personality disorder, let alone dangerous people with severe personality disorder. Also, within the therapeutic community movement, people are struggling with this issue of diagnosis. Nick Manning, Professor of Social Policy and Sociology at the University of Nottingham has recently written a paper entitled ‘Psychiatric diagnosis under conditions of uncertainty: personality disorder, science and professional legitimacy’, (forthcoming in Sociology of Health and Illness), in which he raises the question of why there has been a very rapid elaboration of the category of personality disorder, and particularly severe personality disorder within psychiatric classification over the last twenty years, and seeks an answer through a sociology of psychiatric knowledge, drawing both on recent work on the sociology of science and technology, and on the relationship between psychiatric practice and government in the late 20th century. He suggests that the resulting classification is partly a result of a clear conflict of interests between the profession of psychiatry and the state. He highlights the difficulty and instability of classification systems for personality disorders, particularly in the absence of independent biological tests, or specific links between clinical features and aetiological factors. Manning states that “personality disorder appears to be psychiatry’s equivalent to tonsillitis - widely disputed, denied even to be a medical concern by some, yet for others lurking around every clinical corner”.
Therapeutic communities are concerned about who is going to identify these people, and how; what the grounds for detention are going to be, and who is going to initiate the proceedings and who will make the decision that a person needs this detention? Psychiatrists generally may be unwilling to take this responsibility because this is/may be about containment, not about treatment. Will clinicians in therapeutic communities have to assess for risk, because this will have a real impact on therapeutic work? Finally, what measures will be used to assess dangerous people with severe personality disorder, and will everyone have to do them within the new National Service Framework?
The Home Office itself says that the numbers of those who need to be locked up is few. However, there is a danger of that a large number of people will be locked up, in order to contain the few, particularly given the large number of people with severe personality disorder presenting to general psychiatry. It is also likely that the state’s proposed ability to detain people without mental illness or a conviction will have psychological impact on many (possibly all) individuals, not just those in the specified category of dangerous people with severe personality disorder. Finally, there is also concern that those people who are most dangerous and a risk to the public are not necessarily those with severe personality disorder, and may indeed miss those who are psychotic and dangerous.
The immediate implications of the Government’s proposals for open (i.e. non-secure) democratic therapeutic communities may not be great, and they may not have direct effect. It is difficult to predict what their indirect effect may be: it may be profound, or have no effect at all. Therapeutic communities may take in people with severe personality disorders and later feel unhappy about the level of risk they pose - then what do we do?
If there is a national service for personality disorder, then it is possible that people with severe personality disorders who would otherwise have come to open therapeutic communities may go to secure units, and there is the possibility they may get worse.
If many people with severe personality disorder are all put together, this may prove disastrous for them and the system. Post Ashworth and the Fallon enquiry, psychiatrists are unhappy with admitting people with personality disorder. It is possible more people in mental health services will opt not to have anything to do with personality disorders, because they will not want to make decisions about letting them out.
However, we would like to highlight three core aspects of how a therapeutic community operates and imagine how the present proposals for secure containment and treatment for people with severe personality disorder might impact on these. Firstly, the work of treatment is done through the medium of relationships. Members of a therapeutic community are encouraged to develop attachments to one another, to staff, and to the community as a whole. In this way, the community provided a corrective emotional experience of belonging, which almost always went seriously wrong in the member’s early life. Personality disorder can be viewed as one of the outcomes of, to quote Rex Haigh (1999), ‘a lifelong history of unsatisfactory relationships where the individual learns to expect hostility, abuse, trauma or abandonment’ rather than secure emotional attachments in relations with others. These expectations will be defended against in a variety of ways: excessive dependence, anxious attachment, narcissistic grandiosity, emotional withdrawal, paranoid hostility. Each of these defensive styles will express itself in a different way when the individual joins a therapeutic community: staying in bed, acting out destructive impulses, trying to split the staff group. The task is to replace defensive mistrust with the beginnings of a sense of belonging so that other people come to be experienced as reliable, containing caring individuals. This is a developmental task, in which older members play a significant role in welcoming and supporting new members and also in providing role models for therapeutic engagement and the possibilities of overcoming fears of intimacy.
It would be difficult to establish the initial trust in others if the therapeutic community were part of an assessment process of a person’s dangerousness. In addition, the proposal for centres providing indeterminate detention would undermine the sense of development, moving forwards, from newcomer to engaged member to senior member with the prospect of re-engaging with society again on which the therapeutic community relies. The therapeutic community would become inward looking and risk losing the sense of its own wider relationship with the outside world - one of the factors possibly associated with the eventual closure of Barlinnie Special unit.
Secondly, central to a therapeutic community is what Tom Main called a ‘culture of enquiry’: everything in the community is open to scrutiny, feedback, influence and change as part of the therapeutic process. This is a two way process: staff are not immune, quite the opposite - members can question them about their behaviour just as much as staff can question them and each other. There is little privileged communication. This openness does not come easily, flying as it does in the face of tradition notions of patient-doctor confidentiality, for example. In the therapeutic community, confidentiality extends to the boundary around the community as a whole. The absence of private communication is essential if members are to be confronted with the consequences of their behaviour. The whole point of the therapeutic community is to fully appreciate the way members relate to one another and to themselves, to being together the fragmented parts of the personality, good, bad and awful.
The proposal’s unrelenting emphasis on assessment would undermine this culture of mutual openness, in which it is essential that staff practise what they preach. One can imagine many disclosures not being made and many secret destructive aspects of an individual’s personality remaining hidden if it was expected that assessment of dangerousness was taking place. Of course this is the situation facing all assessment, but it would be the antithesis of therapeutic community culture to ask the staff to perform this role. In particular, the proposal that a fixed prison sentence could be changed to an indefinite on, if a prisoner reveals dangerousness and severe personality disorder during their sentence could have a great impact on prison therapeutic communities which take inmates towards the end of their sentence.
A third core aspect is the way responsibility and decision making are shared between all members - staff and client, in some important areas. These include decisions about new admissions, dealing with rule infringements, and in some therapeutic communities decisions about discharge. Decisions are take by vote in which everyone’s vote counts equally, and staff live with the decision even if they don’t agree. Of course, there may be limits to what can be voted on in this way in each community, but the decision to join a therapeutic community is crucially one that must be taken by all those affected by it.
The proposal for compulsory detention would cut across the goal of empowering members to take responsibility for their own decisions, and would therefore tend to undermine other aspects of the therapeutic community that are empowering. Even in the prison system, the choice to join a therapeutic community such as Grendon is voluntary. There is some evidence that compulsory detention in the early stage of joining a therapeutic community can help to develop attachment to the community and the therapeutic alliance, but this must give way to a voluntary commitment to therapy if the therapeutic work is to be really owned.
So, making an active choice about joining is an important therapeutic principle in most therapeutic communities. Therapeutic communities would want to stick to their principles and ensure that people could opt to be in therapeutic communities, even in secure settings. In other words, people would have to be detained first, and then be offered options regarding treatment, and therapeutic communities could form part of the range of detention options, within which the person could seek to join one. Therapeutic communities also have anxieties about whether staff also will be forced to work in these settings, against their wishes - again, this is against therapeutic community principles. How will this affect their therapeutic alliance. And what about the more subtle ways of pressuring them to do it? Other disciplines are more vulnerable to this than doctors e.g. psychologists, prison officers, nurses.
Also, how will this be financed? There is a danger of repeating the situation following the recent NASCAG recommendations about specialist provision at the Henderson Hospital, and subsequent advice to purchasers about not paying twice.
It is important that resources are not diverted from current services - rather these should be improved, even if a separate service is set up.
Most importantly for us, where are these people going to be put, and what sort of treatment are they going to get? Overall, the Association of Therapeutic
Communities could contribute to discussions on setting up the proposed units as humane and therapeutic psychosocial environments for containing and treating people, even if not specifically as therapeutic communities. More specifically, and quite clearly, given the evidence, some of these patients could be treated in therapeutic communities (although under the Government’s proposals some of these would need to be set up specifically for this purpose - it is not viable to use those existing outside the secure system - while also using those that already exist within the prison and health service system, including the special hospitals, even if in embryonic form). These therapeutic communities would have to be modified to meet the needs for security. However, Lees et al’s (1999) systematic literature review demonstrates that those modified therapeutic communities that already exist in secure settings both in Britain and in North America are effective, both in terms of in-treatment management, and subsequent reconviction.
The Association of Therapeutic Communities would want to recommend that serious consideration be given to explicitly setting up therapeutic milieu environments, where elements of therapeutic community practice are applied in more traditional settings, in the residential accommodation for the dangerous people with severe personality disorder, and that full therapeutic community treatment be made available for a proportion of this group, but only on a voluntary basis (within the constraints of their detaining order), and on the basis of careful assessment and selection, as not all of this group will respond to, or benefit from, therapeutic community treatment, but it is likely that many will. All of this should be evaluated. It is important to identify who is suitable for therapeutic community treatment, who benefits, and in what ways; how the therapeutic community works effectively, and how the service can be improved. It would be a wasted opportunity not to use research to evaluate the implementation of theses proposals from the beginning.
If these proposals go ahead, and whatever form they take, the developments should be examined and evaluated on an action research type footing: they should be set up slowly, with a willingness to continually learn and modify as they develop, and to research the impact of change and modify things accordingly. Once set in terms of accepted procedures, treatment is unlikely to remain therapeutic.
Janine Lees/David Kennard
Members of the Association of Therapeutic Communities
December 1999
Association of Therapeutic Communities Steering Group, 1999, The Need for an NHS Policy on Developing the Role of Therapeutic Communities in the Treatment of ‘Personality Disorder’, London, Association of Therapeutic Communities
Chiesa, M., Iacoponi, E. & Morris, M., 1996, Changes in Health Service Utilization by Patients with Severe Personality Disorders before and after Inpatient Psychosocial Treatment, British Journal of Psychotherapy, 12, 4, 501-512
Cullen, E., 1993, The Grendon Reconviction Study Part I, Prison Service Journal, 90, 35-37
Davies, S., Campling, P. & Ryan, K., 1997, Does every district need a therapeutic community?, Unpublished paper, Francis Dixon Lodge, Leicester
Dolan, B. M., Warren, F. M., Menzies, D. & Norton, K., 1996, Cost-offset following specialist treatment of severe personality disorders, Psychiatric Bulletin, 20, 413-417
Dolan, B., Warren, F. & Norton, K., 1997, Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder, British Journal of Psychiatry, 171, 274-279
Haigh, R., 1999, The Quintessence of a therapeutic Environment: Five Universal Qualities, in Campling, P. & Haigh, R., (Eds.), Therapeutic Communities: Past, Present and Future, London, Jessica Kingsley
Lees, J., Manning, N. & Rawlings, B., 1999, Therapeutic Community Effectiveness. A Systematic International Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. CRD Report 17, York, NHS Centre for Reviews & Dissemination
Marshal, P., 1997, A Reconviction Study of HMP Grendon Therapeutic Community. Research Findings No. 53, London, Home Office Research and Statistics Directorate
Norton, K. & Hinshelwood, R. D., 1996, Severe Personality Disorder. Treatment Issues and Selection for IN-Patient Psychotherapy. British Journal Of Psychiatry, 162, 299-313
Rice, M. E., Harris, G. T. & Cormier, C. A., 1992, An Evaluation of a Maximum Security Therapeutic Community for Psychopaths and Other Mentally Disordered Offenders, Law and Criminal Behaviour, 16, 4, 399-412
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