Annex
EDITORIALS
DANGEROUS PEOPLE
WITH SEVERE
PERSONALITY DISORDER:
BRITISH PROPOSALS
FOR MANAGING
THEM ARE
GLARINGLY WRONG
AND UNETHICAL.
This summer the British Department of Health and
the Home Office jointly issued a paper on Managing Dangerous People
with Severe Personality Disorder[1].
The paper was apparently "based on the results of extensive
informal discussions" and sets out the government's policy
objectives in dealing with what the paper calls the "dangerous
severely personality disordered". The paper avoids descending
into the apparently unending debate over what is, or is not, a
personality disorder and to what extent personality disorders
are treatable and attempts to cut through the gordian knot with
what presumably are intended as straightforward and practical
proposals for action. If only it were that simple.
This government "framework for the future"
proposes legal powers for detaining indefinitely people with dangerous
severe personality disorder. Specialists, including psychiatrists,
are to be employed both to better identify people with dangerous
severe personality disorder and to develop "approaches to
detention and management." Finally a comprehensive programme
of research is to be established to support development of policy
and practice. The proposals make a point of insisting that "indeterminate
detention will be authorised only on the basis of evidence from
an intensive specialist assessment" (my italics).
There are people whose antisocial and self damaging
behaviours are at least in part a product of abiding character
traits such as impulsivity and suspiciousness combined with abnormalities
of mental state, including instability of mood and dissociative
symptoms. Such distressed and disturbed individuals currently
attract little interest from mental health professionals and even
less from those who fund services. Clinical experience suggests,
however, that such disorders can be improved, if not cured, even
if research has failed to pinpoint the best therapeutic approaches.
Severely personality disordered individuals are over-represented
among recidivist offenders, though such disorders do not inevitably
lead to serious offending; nor are serious offenders drawn exclusively
from their ranks.
Crime and violence are major political issues.
Surveys indicate growing public support for more punitive approaches
to offenders,[2]
and populist governments around the world, be they left, right,
or third way leaning, fall over themselves to respond to law and
order agendas. In England and Wales section 2 of the Crimes (Sentencing)
Act already provides for discretionary life sentences for those
convicted a second time for serious violence or a sexual offence.
The courts have, however, shown a signal lack of enthusiasm for
imposing such sentences, frustrating the government's carceral
enthusiasms. The proposals set out in this document openly acknowledge
the hope that the judicial reluctance to sentence on the basis
of predicted future behaviour will be reduced if courts are provided
with medical evidence that offenders have dangerous severe personality
disorder.
What is wrong then with proposals that promise
far greater resources for a relatively ignored group of mentally
disordered people and at the same time hold out the prospect of
increased community safety? If dangerousness was really a characteristic
of some personality disordered individuals rather than a characteristic
of some acts by some of them; if the proposed special centres,
with their multidisciplinary teams armed with "batteries
of standardised procedures", could reliably recognise dangerous
severe personality disorder; if these proposals were really about
providing care and treatment for the personality disordered; and
if health professionals were really judges and jailers charged
with maintaining pubic order, then perhaps these proposals would
be worth taking seriously. But none of these assumptions holds
true.
Enthusiastic advocates exist for actuarial methods
of predicting future criminality, and some place considerable
theoretical emphasis on the contribution of personality.3, 4 In
practice, however, the probability of future offending is predicted
most effectively by past offending.5 Variables such as being a
substance abuser or having a history of being abused as a child,
have significant, if less consistent, associations with increased
rates of future violence.4, 6 Mental health variables contribute
little to such predictive characteristics. A diagnosis of psychopathy,
or antisocial personality disorder, often does little more than
recycle the history of prior offending behaviours in a different
form, producing a potentially spurious association between personality
disorder and offending. In practice, therefore, we would be identifying
people with dangerous severe personality disorder not on mental
health, or even personality, variables but on their past offending,
their past history of victimisation, and their current drug and
alcohol habits. Except for substance abuse, none of these predictive
factors is open to change.
The government's proposals masquerade as extensions
to mental health services. They are in fact proposals for preventive
detention, not too far removed from the dangerous offender and
sexual predator laws in North America.5 They aim to make judges
more amenable to imposing discretionary life sentences. They are
intended, as Eastman observed in these pages,7 to circumvent the
European Convention on Human Rights, which prohibits preventive
detention except in those of unsound mind. With their promises
of new money and research funding, they hope to bribe doctors
into complicity in the indefinite detention of certain selected
offenders. Discussion of the ethical dilemmas that these proposals
present for health professionals is absent, presumably because
they are ethically and professionally indefensible.
There is a crying need for mental health services
for severely personality disordered individuals. Such services
would decrease the morbidity and staggering mortality associated
with these conditions. In the process they would contribute to
community safety. The British government's proposals largely ignore
this central issue of developing appropriate treatment services
in favour of creating a system for locking up men and women who
frighten officials. On first reading this document created both
disappointment and foreboding. On more careful consideration it
became clear that the contradictions were so glaring, the deceptions
so open and palpable, and the agenda so obvious, that these proposals
can surely not have any chance of influencing reality.
PAUL E MULLEN,
PROFESSOR OF
FORENSIC PSYCHIATRY.
MONASH UNIVERSITY
AND INSTITUTE
OF FORENSIC
MENTAL HEALTH,
VICTORIA 3084, AUSTRALIA.
REFERENCES:
1. Department of Health, Home Office. Managing
dangerous people with severe personality disorder. London: Home
Office, 1999. http://www.homeoffice.gov.uk/cpd/persdis.htm
2. Kury H, Ferdinand T. Public opinion and
punitivity. Int J Law Psych 1999; 22:373-392.
3. Hare RD. The Hare PCL-R: some issues
concerning its use and misuse. Legal Criminol Psychol 1998; 3:99-112.
4. Quinsey VL, Harris GT, Rice ME, Cormier
CA. Violent offenders: appraising and managing risk, Washington,
DC: American Psychological Association, 1998.
5. Heilbrun K, Ogloff JRP, Picarello K.
Dangerous offender statutes in the United States and Canada: implications
for risk assessment. Int J Law Psych 1999; 22:393-415.
6. Steadman HJ, Mulvey E, Monahan J, Robbins
PC, Appelbaum PS, Grisso T, et al. Violence by people discharged
from acute psychiatric inpatient facilities and by others in the
same neighbourhoods. Arch Gen Psych 1998; 55:393-401.
7. Eastman N. Public health psychiatry or
crime prevention? BMJ 1999; 318:549-551.
1 "Fitness for Practice" (1999) the UKCC
Commission for Nursing and Midwifery Education. United Kingdom
Central Council for Nursing Midwifery and Health Visiting. London. Back
2
Health Committee, Fifth Report 12 July 1999 Vol. p xxii. Back
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