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EDITORIALS: Nigel Eastman Public health psychiatry or crime prevention? BMJ 1999; 318: 549-551 [Full text]

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Psychiatry's Star Chamber

Andrew Al-Adwani   (31 March 1999)

Public Health Psychiatry: Nothing New.

John J Sandford   (2 April 1999)

Psychiatry's Star Chamber 31 March 1999
Andrew Al-Adwani Send response to journal: Re: Psychiatry's Star Chamber	Eastman highlights some of the problems the government might encounter in enacting it recently proposed legislative changes.1If half of all government ministers, most who seem to be enthusiastically spouting the party line on incarceration of untreatable psychopaths, realised that using the accepted diagnostic manuals, they would be odds on to meet the criteria for at least one of the personality disorders, the wind, whatever its temperature, might taken from their sails. There are criminals who get caught, some who escape the law and many who hover around the fringes of lawlessness. Most are not the sort that you would entrust the feeding of your fish to and they, not unsurprisingly, are more likely to go away than you are. Somewhere in between are a ragbag of misfits who annoy, pester, pilfer, behave oddly, obnoxiously or angrily, decline work and defy authority. Neither group are necessarily 'mad', in the sense that they know beyond reason that what they hear and believe is fact when this is patently not so, but many are beyond reason insofar as they can see no rationale for a life beyond the one they live. Intervening in the case of those who are 'mad' is not difficult. One or other agency, be it the police, concerned citizen, doctor or priest will either take the person or call for the person to be taken to a place of safety. Though in present times this may amount to no more than the removal of an embarrassing nuisance, occasionally more than lip service will be paid to treatment. Doctors, social workers and the police have powers to do this and more. There remain a small and vociferous minority who cause great difficulty to both the public and the caring services. They are almost universally despised and uniformly untreatable, with for doctors the latter sometimes fuelling the former, and in many cases thereby confirming the diagnosis. These are people so like us that we cannot excuse their outrageous behaviour. Only those who have lived the most cloistered of existences can have escaped their depredations though even they are likely to find attenuated versions amongst themselves. These are the personality disorders. Various typologies have been used to classify them and some, having found 'caseness', treat them. Others concentrate on particular types and determine treatability according to severity usually discarding those who exceed a certain threshold as being beyond therapy. Found within this group are the predatory, coldly violent, impulsive, perverted, murderers and rapists who grab our newspaper headlines. Almost without fail they come to our attention through their atrocities and rather than flounder impotently we call for more police, better laws and more protection. The latest idea has been to incarcerate untreatable psychopaths even before they have offended. There is something of the mentality that created the Gulags in this. The presumption of sedition in the writings of an author on the basis of somebody else's reading and interpretation was more than enough in Stalin's day to ensure a long 'holiday' in the north. Who will be Blair's censors? Will doctors go down the Soviet road that resulted in their expulsion from world psychiatry? Will the third way encompass a third class; not bad, not mad but not wanted. This is not a workable proposal. If the aim were to give psychiatrists the power to detain those who are being released on the grounds of untreatablility, the simple solution would have been to broaden the definition of treatability. Even this may not have been needed as there already exists within treatablity the concept of prevention of deterioration. Nobody could argue that prevention of deterioration would not be the universal result if a serious offence were prevented. Instead we have looming the rather frightening spectre of a true thought police, most likely run in conjunction with doctors, together determining the fate of many hundreds of thousands of people they basically don't like. What chills me most is that I can think of a number of doctors who would join the ranks of this modern day inquisition with enthusiasm. Andrew Al-Adwani MRCPsych Sheffield Outreach Team Park Health Centre Sheffield, South Yorkshire
Public Health Psychiatry: Nothing New. 2 April 1999
John J Sandford, Specialist Registrar Langdon Hospital, Dawlish, Devon. Send response to journal: Re: Public Health Psychiatry: Nothing New.	PUBLIC HEALTH PSYCHIATRY - NOTHING NEW Your recent editorial (1) brought the debate about dangerousness and mental disorder to a wider audience. Unfortunately it failed to point out that the preventative detention of those with untreatable mental disorders is already widely practised in this country. Under the Mental Health Act (1983) (2) those with mental illness or severe mental impairment can be detained indefinitely in hospital regardless of response to treatment and on grounds of risk to self as well as others. Secure and open psychiatric hospitals are full of such patients. If the author was concerned that possible new legislation might challenge both the “civil liberties of the unconvicted and those designated untreatable” then surely this concern should extend to the current legislation affecting those with a mental illness or mental impairment. Many psychiatrists find it convenient to make a strong distinction between personality disorder (a largely social condition) and mental illness/impairment (a wholly medical one) and hence view them from different ethical standpoints. Unfortunately modern neurobiology fails to see such a clear distinction (4). It seems paradoxical that the statistically less dangerous mentally ill are subject to easier and more widespread detention than the more dangerous personality disordered. There is little moral, medical or scientific distinction between those suffering from mental illness (i.e. Asperger’s Syndrome) and those suffering from personality disorder (i.e. schizoid personality disorder). The government’s proposals are that doctors’ current role as public protectors should be extended to include both groups. This does pose new clinical, legal and practical problems, but no new ethical ones. REFERENCES 1) EASTMAN, N. Public Health Psychiatry or Crime Prevention? BMJ 1999 ; 318: 549-51 2) Mental Health Act (1983) Section 3, 37, 47 3) HOLLANDER, E. STEIN D. J. Impulsivity and Aggression (1995) John Wyley and Sons Dr John J Sandford, Specialist Registrar in Forensic Psychiatry.