Who should take responsibility for antisocial personality disorder?

News p 211 and Personal viewp 271

The diagnostic boundaries and treatability of personality disorders have always been medically controversial. Whether offenders with antisocial1 or dissocial2 personality disorder—“a most elusive category [with] wavering confines”3—should be treated in hospital or punished in prison is profoundly controversial. Now, because of highly publicised cases of paedophilic violent offenders released from prison and the case of Michael Stone, a convicted psychopathic murderer, the medical response to personality disorder has become a subject of national political debate. The dispute between the home secretary4 and the president of the Royal College of Psychiatrists5 about whether psychiatrists should be preventively detaining untreatable psychopaths under the Mental Health Act illustrates well the field of political conflict.

Into this debate comes the Fallon inquiry into the personality disorder unit at Ashworth high security hospital.6 This will soon be followed by the announcement of government policy on future services and legal provisions for personality disordered offenders, arising out of a Home Office-Department of Health working party that has been running in parallel with the inquiry. Fallon investigated and largely confirmed complaints of patients trading in pornographic material, a young child visiting convicted dangerous paedophiles and being “groomed” for abuse, patients running ward businesses, misuse of drugs and alcohol, and gross lapses in security. The report juxtaposes its general description of “the patients running the hospital” with the findings of “staff abuse of patients” by the 1992Blom-Cooper inquiry into the same hospital,7 nicely capturing the problem of integrating therapy and custody for a group of patients who are particularly adept at manipulation. The Fallon report found the personality disorder unit to be “a deeply flawed creation” but extended its recommendation of closure to the whole hospital, describing its management culture as “dysfunctional …secretive, out of touch and totally unable to control this large institution.”

Although heavily criticising senior managers and clinicians alike, the report lays blame ultimately at the door of the management system, concluding “we have no confidence in the ability of Ashworth Hospital to flourish under any management.” It makes two further recommendations about “the system.”

Firstly, all high security services should be integrated into regional forensic and general mental health services. This is a widely and long held professional view to which the Department of Health is already committed: it intends regional commissioning of both high and medium secure services and the integration of Ashworth, Rampton, and Broadmoor special hospitals into general mental health trusts. However, the department has rejected both closure of Ashworth and the relocation of all high security services into smaller regional forensic networks (presumably because of cost).

Secondly, the Fallon report offers an interesting critique of the whole system of accountability within the NHS. In recommending the apparently politically uncontroversial notion that accountability, even in the absence of personal blameworthiness, should extend to the secretary of state, the report observes, by contrast, “We can recall no example of a minister resigning as a consequence of a failure in the NHS in all its 50year history.” This suggestion has implications which go far beyond Ashworth and forensic mental health services. It touches broadly on both accountability in the NHS and the relation between clinicians and their managers (likely to be subject to major change after the Bristol Royal Infirmary inquiry) and between politicians and NHS staff. Acceptance of Fallon's recommendation that there should be a direct line of accountability from health authorities to the NHS executive and, ultimately, to ministers would result in accountability for system failures being properly placed on managers and politicians rather than on clinicians.

Fallon's specific recommendation about personality disorder services is that they should be delivered within small specialised units in both high secure hospitals and prisons, with easy transfer between the two and the development of nationally agreed assessment and treatment protocols. This is sensible. It reflects the poor state of research knowledge about treatability8 and the therapeutic ambivalence9 and consequent uncertainty about whether the condition should be managed more by therapy (therefore in hospital) or by custody (therefore in prison). What remains unclear is whether effective treatment can, or will, occur in prison.

Responsibility for protecting the public from mentally ill people has increasingly been placed on psychiatrists. For personality disordered people, however, Fallon recommends abolishing orders made by courts to hospital, in favour of penal sentencing with legal transfer to hospital during the sentence for those who are deemed treatable and are consenting. For severely personality disordered offenders there would be a “renewable sentence”: if at the end of his tariff the offender was deemed still to be dangerous his sentence would be renewed for a further two years, and potentially thereafter. The untreatable psychopath would presumably therefore stay in custody indefinitely—which raises human rights issues.

Penal sentencing combined with transfer to hospital would acknowledge the morally hybrid nature of such offenders—who combine “madness” and “badness.”10 It would also avoid achieving preventive detention on the pretence of medical treatment. However, even renewable sentences will not deal with the Home Secretary's concern about those who are dangerously disordered but unconvicted. Here he turns solely to psychiatrists, who he perceives as overcautious in their (correct) interpretation of the current law that untreatable psychopaths cannot be detained in hospital.4 If the Guardian is correct in its prediction that the Home Office-Department of Health review will result in “a new form of renewable detention …not to be confined to offenders,”11 and presumably including the untreatable, then doctors may find that, in contrast to Fallon's recommendation, they are to be held more responsible for the safety of the public from psychopaths. We wait to hear soon whether the government will accept Fallon's recommendations, including the holding of politicians properly responsible for failures in the NHS.