APPENDIX 10
Memorandum by the Mental After Care Association
MANAGING DANGEROUS PEOPLE WITH SEVERE PERSONALITY
DISORDER (DSPD)
MACA
MACA is a leading national mental health charity
serving people with mental health needs and their carers. We are
partners with over 50 health and local authorities. We provide
housing with support; community support to people living in their
own homes; respite care; day schemes, including employment training;
advocacy; and services for people in contact with the criminal
justice system. Some of our users have had a diagnosis of personality
disorder.
THE DIFFERENCE
BETWEEN PERSONALITY
DISORDER AND
MENTAL ILLNESS
Far from being the strident "sweep them
off the streets" plan that had been heralded, the Government's
consultation document actually reflects the real complexity of
many of the issues in a thoughtful way. Yet the next day The
Sun ran the banner headline "600 PSYCHOS TO BE LOCKED
UP—SWOOP ON MANIACS BEFORE THEY STRIKE". It illustrates
the depth of public misunderstanding on the real issues involved
and helps explain why so many people with mental health problems
are feeling threatened by a climate that simplistically equates
mental illness with DSPD and violence.
We believe it is essential for any discussion
of personality disorder to acknowledge the difference between
personality disorder (eg Michael Stone) and mental illness (eg
Christopher Clunis). The provisional findings of our survey of
staff and users of MACA services, undertaken specifically for
the Government's consultation exercise, indicate that 95 per cent
of people in general do not understand the difference.
Personality disorder (or "psychopathic
disorder" in the current Mental Health Act 1983) is defined
by the consultation document as:
"an inclusive term referring to a disorder
of the development of personality. Personality disorder is not
a category of mental illness, but a diagnosis of personality disorder,
like mental illness and other mental disorders, can potentially
be regarded for legal purposes as a cause of `unsound mind' .
. . Not all people with severe personality disorder present a
risk to society or to themselves."
While personality disorder is not a mental illness,
people with this diagnosis can also suffer from a mental illness,
such as manic depression. Although there are more specific clinical
categories of personality disorder, in general psychiatry it is
not unusual for someone with a long psychiatric history to have
the label attached to them along with a series of mental illness
labels, because they have gone through a phase when their behaviours
(sometimes induced by medication) have not been explicable in
terms of accepted diagnostic categories of mental illness.
DIAGNOSIS OF
PERSONALITY DISORDER
One of our major concerns about the proposals
is that there are major problems in accurately diagnosing and
identifying people with severe personality disorders. Psychiatric
opinion is divided as to whether this is a valid medical diagnosis.
Misdiagnosis is inevitable. Personality disorder is a "dustbin"
diagnosis, including a range of conditions that can in no way
be considered dangerous to others.
THE SCALE
OF THE
PROBLEM
Government figures estimate that there are around
300 to 600 people with DSPD in the community. As around 380 people
with DSPD leave prison and special hospital each year, this suggests
that there are only a very small number of potentially dangerous,
but as yet non-offending people with severe personality disorders
in the community at any one time who are not known to any of the
specialist criminal justice or forensic services.
However small the numbers, there are undoubtedly
concerns about the potential human rights infringements involved
in locking up someone indefinitely on the supposition of potentially
dangerous, seriously anti-social behaviour when no crime has been
committed. This seems particularly important to establish, so
as not to drive people away from potential sources of help through
fear of being labelled DSPD and locked away.
ASSESSMENT OF
RISK
Home Office Minister Paul Boateng has said that
the Government proposes to move away from a system where whether
someone is detained or not depends solely on whether they commit
a criminal offence or whether a psychiatrist thinks they are treatable.
The new proposal is for a system in which decisions on detention
would be based on the risk the person presents.
Our chief concern here is that, although there
are risk assessment tools available, there is no absolutely reliable
way in which the dangerousness of an individual can be predicted.
Who will judge when risk becomes "severe" or "dangerous"?
These are not absolute concepts. There is a strong possibility
that people who have not, and will not, commit any crime will
be indefinitely detained. And although their detention will be
subject to periodic review, if they are considered "untreatable",
how will they ever be able to demonstrate they no longer pose
a threat to public safety?
In addition, any system based on risk needs
to accept that the risk of harm to the general public from someone
with a severe personality disorder is very small compared to,
say, the risk from reckless drivers or alcohol-related violence.
THE TWO
OPTIONS IN
THE CONSULTATION
PAPER
The Government has made it clear that doing
nothing is not an option. Two options are proposed: one (A) modifies
and improves the existing arrangements for such people in prison
and in hospitals; the other (B) envisages a single specialist
agency dealing with all these people. Both options include enhanced
powers of detention, supervision and recall, though it is B which
contains proposals for detention of people diagnosed as DSPD where
the person has not committed a crime. This clearly poses questions
about human rights.
The findings from our research show a two-thirds
support for the first option (A). This is the option we would
provisionally support (subject to our final response to the Government
at the end of December 1999). Importantly, it is the one closest
to what should be one of the main aims of the whole exercise—how
to engage in a genuine debate about the best way to help people
with DSPDs and protect the public as far as possible. Such a debate
would serve two purposes—first, to improve our understanding
of how we should be addressing the needs of this group; and second,
to clarify once and for all the distinction between mental illness
and personality disorder.
In addition, problems which have already been
raised in respect of option B include
— the enormous cost of introducing
new facilities—somewhere between a hospital and a prison—for
this group of patients;
— the difficulty of getting anyone
willing to work in these new facilities, if all the patients are
considered "untreatable";
— the human and civil rights issues
around detention where no crime has been committed and no mental
illness diagnosed.
SUMMARY
We understand the Government's concern to protect
the public from dangerous individuals. But
— it would be quite wrong to detain
indefinitely people who have committed no offence on the basis
of a diagnosis of severe personality disorder, about which psychiatric
opinion is divided; there are major problems in accurately diagnosing
and identifying people with severe personality disorders;
— it would be far more constructive
to learn from the best of current practice about engaging these
people and to commit additional resources to replicating such
services;
— there is no reliable way in which
the dangerousness of an individual can be predicted;
— we want to help the Government develop
workable and effective measures, but introducing new powers of
indefinite detention will only drive users away from services,
which is in no one's interest.
October 1999
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