APPENDIX 12
Memorandum by Dr Ruth S Cooklin MB ChB
MRCPsych, Consultant Psychiatrist
LETTER TO THE CLERK OF THE COMMITTEE
Re: "Managing dangerous people with severe
personality disorder"—Proposals for policy development.
The Government's proposals to lock up potentially
dangerous people who have not yet committed a serious violent
offence are alarming and I believe would be unworkable, inhumane,
wasteful of scarce resources and would present an unacceptable
threat to civil liberties.
Despite being, in world terms, a relatively
mature, democratic nation, we abuse already, through our continuing
primitive, instinctive attachment to the concept of punishment,
the human rights of many of our most vulnerable citizens. Tens
of thousands, including even some of our most damaged children
and young people, are incarcerated in the punitive, unsafe, often
brutalising environment of the prison system. Many suffer from
mental disorders and the majority, although not having a formal
mental illness, also have serious mental or psychological problems
due to combinations of learning difficulties, social deprivation
and childhood experiences of neglect, loss and abuse. As a consequence,
they have developed problems in their perception of themselves
and others and in the way they relate to other people and to their
communities. Such people are often described as having personality
disorders. A recent study reported in the "Archives of General
Psychiatry" (1999;56;600-6) found that particular forms of
childhood mistreatment were associated with different types of
personality disorder.
Thus, currently, we take our most damaged citizens,
most of whom are either brain disordered and or have been damaged
through no fault of their own by the circumstances of their lives,
and judicially damage them further. Under the Government's new
proposals, there would be considerable risk of damaging even more.
I am not a forensic psychiatrist but I have
over 25 years extensive clinical experience both in the NHS and
in the private sector and I have had a longstanding interest in
legal and human rights issues. At present, I am working part-time
in the private sector with adults and adolescents and I am a professional
adviser for a children's mental health charity.
There remains much controversy and equivocation
concerning the diagnosis and prognosis of personality disorders
and risk assessment remains an inexact science, previous violence
alone being the best predictor of future violence. If that is
the current state of knowledge and confidence, how can we possibly
consider detaining against their will those who have not yet committed
a serious act of violence and may never do so? And, who is going
to decide whom to detain? Such absolute power over others could,
in the wrong hands, be very corrupting and might well attract
to such powerful positions those with non-violent but perhaps
similarly dangerous controlling, punitive personality traits.
The risk of mistakes, injustice and abuse would be simply unacceptable
in a free society.
Human psychological complexity severely limits
our ability to place individuals into simplistic, strict diagnostic
categories. Many have multiple problems some more easily treatable
than others. Any of us given a particular combination of factors
and circumstances is capable of violence and many law-abiding
citizens harbour violent fantasies which they will never act out.
If we plan to lock up all those with violent ideation then we
could incarcerate every horror story writer and film producer
and all those who enjoy their creations. Indeed, that would include
almost everyone.
I am neither naive nor very brave. I have been
a victim of crime on several occasions and I am as fearful for
my own and my family's safety as anyone. Someone who commits a
serious violent offense has to be removed from society in order
to protect the rest of us. But, society must understand that such
violent individuals, however heinous their crimes, are not monsters,
that they are still people, albeit very disturbed people, and
that as a society, we created and cannot disown them. As such
they deserve to be contained in therapeutic environments and offered
whatever intervention or treatment may reduce their dangerousness,
prevent their further deterioration and improve their quality
of life with the ultimate aim, if at all possible, of re-integrating
them into the community.
Treatability has become the big issue highlighting
the shortcomings of the current Mental Health Act. This Act neither
defines mental illness nor adequately protects the civil rights
of the mentally healthy or unhealthy. The treatability clause
was meant to prevent non-mentally ill people being detained in
hospital against their will but, in practice, it has allowed those
suffering from serious mental ill-health rather than a formal
mental illness to be locked up in prison instead. The Act should
define mental illness. It could be extended to include those with
clearly defined serious personality disorders but to prevent abuse
or mistakes extremely strict guidelines and protections would
have to be incorporated. There is, in addition, the very serious
problem that the criminal justice system does not share the same
concepts of or use the same terms concerning mental disorders
as mental health professionals, a wholly unsatisfactory situation.
The whole area of mental health and how it relates to offending
and disposal of offenders and the fundamental ethos and underlying
principles of the justice system need to be addressed. The problem
of mentally dysfunctional offenders or potential offenders raises
all these related issues.
Declaring someone untreatable, however, says
more about the treatment skills of the treating professional than
it does about the treatability of the patient. Few of us in this
era of increasing specialisation can lay claim to the necessary
skills and knowledge required for all mental health problems.
There is so much more to mental health than just the absence of
formal mental illness. There are professionals, admittedly not
very many and not necessarily psychiatrists, who possess the skills
to treat the personality disordered but they and their effective
methods are often denied the respect and recognition they deserve,
due probably to a combination of political, public and professional
ignorance, professional jealousy, idealogical and agency turf
wars and competing demands upon resources. Dismissing someone
and his problem as untreatable leaves him unsupported and further
alienated. Difficult problems should be viewed as a challenge
not as an excuse to abnegate responsibility and condemn numerous
damaged people to a form of purgatory.
I doubt, however, that it will be psychiatrists
rising to this challenge. Sadly, many of my colleagues seem intent
on reducing themselves out of existence. Over the past 20 years
or so, due to underfunding, increasingly low morale and less eclectic
training, we have restricted our responsibilities and treatment
skills to fewer and fewer diagnostic categories, leaving the vast
majority of mental ill-health either to other disciplines or agencies
or very often to no-one at all. Psychiatrists seem generally not
well-equipped or trained to treat personality disordered patients
or are, perhaps, too medically orientated to adopt and feel comfortable
with the mixture of psycho-analytic and cognitive-behavioural
skills required to treat what can be a very difficult, disruptive,
and, in the short term, ungratifying group of people to treat.
If so, the responsibility for such patients should be handed over
to other suitably trained professionals.
Perhaps too, a large part of the problem is
the way we as a society perceive mental ill-health and human behaviour.
Society's and some of our speciality's continuing attachment to
the simplistic classifications of mad-sad-bad should be consigned
to the dustbin as should our similar atavistic attachment to the
need for punishment. Society as a whole fails to acknowledge the
very complex, vulnerable nature of its citizens and to accept
that life is a risky business. The Government and mental health
professionals should be educating the public to understand that
people who have personality disorders may express their difficulties
through anti-social behaviour but they have, in fact, underlying
serious mental health or psychological problems. Such people are
failed during their childhoods by the adults in their lives and
are then punished for being victims. They are just as deserving
of effective intervention as those with any other form of mental
disorder. Punishment and retribution should play no part. You
cannot hurt and hope to heal people at the same time.
Rather than risk, at great financial expense,
seriously infringing the civil liberties of a potentially large
number of unconvicted people I would recommend that the Government
should provide adequate financial resources for:
(1) containing in therapeutic environments
and treating those who have already offended and are known to
be dangerous;
(2) educating the public to better understand
the situation and to accept the small but inevitable risks of
human existence; and
(3) the early detection of and intervention
with emotionally and behaviourally disturbed children and young
people in order to prevent the development of personality disorders
in the first place.
Finally, while risk assessment remains such
an inexact science, detaining, possibly indefinitely, people who
have not yet committed a seriously violent act cannot be justified
and in order to prevent injustice and to protect all our civil
liberties, the public may have to forfeit the currently fashionable
precautionary principle and accept the risk. Should the government
try to bring in such a policy which would set a very dangerous
precedent, I would suggest that the profession of psychiatry protest
and have nothing to do with it.
21 September 1999
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