Public health psychiatry and crime prevention

British Medical Journal, May 15, 1999 by John J Sandford, Derek Summerfield

Preventive detention of mentally ill people is already widespread

EDITOR--Eastman's editorial brought the debate about dangerousness and mental disorder to a wider audience.[1] Unfortunately, he failed to point out that the preventive detention of those with untreatable mental disorders is already widely practised in England. Under the Mental Health Act (1983) people 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 Eastman 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 people 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 or impairment (a wholly medical one) and hence view them from different ethical standpoints. Unfortunately, modern neurobiology does not make such a clear distinction.[2] It seems paradoxical that statistically less dangerous mentally ill people are subject to easier and more widespread detention than the more dangerous people with personality disorder.

There is little moral, medical, or scientific distinction between people with mental illness (that is, Asperger's syndrome) and those with personality disorder (that is, schizoid personality disorder). The government's proposals are that doctors' current role as public protectors should be extended to include both groups. This poses new clinical, legal, and practical problems but no new ethical ones.

John J Sandford Specialist registrar in forensic
psychiatry
Forensic Psychiatry Service, Butler Clinic, Landon
Hospital, Dawlish, Devon EX7 0NR

[1] Eastman N. Public health psychiatry or crime prevention? BMJ 1999 318:549-51. (27 February.)

[2] Hollander E, Stein DJ. Impulsivity and aggression. Chichester: John Wiley, 1995.

Psychiatry cannot protect public from people with personality disorder

EDITOR--Eastman rightly notes that the prospect of indeterminate detention of people who face no criminal charge but are deemed to have "antisocial personality disorder" raises ethical questions for psychiatrists.[1] The growing pressures on them to deliver public protection was perhaps inevitable, given the rise of biopsychomedical paradigms as explanations for the vicissitudes of life in modern Western society.

Psychiatrists have played their part by assuming the authority to explain, categorise, manage, and prognose in situations where well defined disease (arguably their only clearcut remit) was not present. But despite decades of clinical practice and research there is still no compelling case for personality disorder to be regarded as a medical condition. As a psychiatric trainee I was taught that the only solid predictor of someone committing violence in the future was whether he had done so in the past. This is scarcely a nugget of psychiatric wisdom. The steady rise of violent crime in Britain and elsewhere is not because of undiagnosed "antisocial personality disorder," which is as much the product of social and situational processes as of individual ones.

History shows that when psychiatric models reach out too far into society, the profession comes to look ethically exposed. In 19th century America, slaves who ran away from their masters were deemed to have a mental illness called drapetomania,[2] and in recent times "sluggish schizophrenia" was held to explain and discount the opinions of political dissidents in the Soviet Union. When is the medicalisation of social control legitimate? If psychiatry is to be realistic and ethical, it must publicly admit that it cannot protect the British public from the majority of acts of violence since these are committed by people whom its disease models and thus treatments do not capture.

This admission questions even current remits. On the one hand, it may be unfair to blame consultant psychiatrists when a patient with "personality disorder" kills someone. On the other hand, psychiatrists might have to relinquish that part of their power, status, and salary which they currently claim in relation to their responsibility for such people.

The real arena is sociomoral and political. The withering of extended family networks, the entrenching of systemic underemployment, the diverging economic fortunes of "haves" and "have nots" are all fraying the social fabric, the degree of connectedness of which is the major anticrime variable.

Derek Summerfield Psychiatrist
Medical Foundation for the Care of Victims of
Torture, London NW5 3EJ

[1] Eastman N. Public health psychiatry or crime prevention. BMJ 1999;318:549-51. (27 February).

[2] Fernando S. Mental health, race and culture. London: MIND Publications, 1991.