Monstermouse nurse pirate tykim@monster, monster tykim@monstermonster_jybooks.com.
A millennium monster is born
4
Editorial A millennium monster is born The English have invented a new disease. It is called dangerous severe person- ality disorder or DSPD for short. Perhaps it is no surprise that the English have invented a new disease, the Americans do it all the time if we are to judge by the exponential growth in the number of diagnoses listed in the DSM series. Please note, however, that it is the English who have invented this new disease; so far it has not spread to other parts of the United Kingdom. Another unusual feature is that this disease was invented by politicians. At the end of last year, the English Home Office issued a consultation document about the management of individuals suffering from this new disease (Home Office, Department of Health, 1999). Proposals included a whole new devel- opment of institutions which would be neither prisons nor hospitals, but a ‘third way’, and special legal provisions for detaining the sufferers from the dis- ease against their wishes, even if they had not committed an offence because, by definition, they would be dangerous individuals. Strangely the politicians already have a lot of information about this dis- ease, even though ‘decisions on the direction of policy development for man- aging dangerous people with severe personality disorder cannot be delayed until the outcomes of conclusive research are known’. The Home Office esti- mates that there are ‘just over 2000 people who would fall into this group in England and Wales’, over 98% of whom are men and mostly in prison or secure hospitals. In an appendix to the Home Office document we are told that there are 1422 adult male sentenced prisoners suffering from this condi- tion in prisons in England and Wales – these are prisoners diagnosed in a recent survey using SCID II as suffering from antisocial personality disorder who also had 6+ risk factors for recidivism. A further 400 male patients are detained on court orders under the English legal category of ‘psychopathic dis- order’ in secure hospitals and ‘it is estimated’ (how, we are not told) that there are a further 300–600 such individuals in the community. The Home Office also seems to know that £89 million a year (not £90 million you will be relieved to learn) is ‘being spent on the 1800 DSPD individuals in detention’. Most readers will be aware that antisocial personality disorder is an unsatis- factory diagnosis based partly on criminal history, so adding risk factors for Criminal Behaviour and Mental Health, 10, 73–76 2000 © Whurr Publishers Ltd 73
Transcript of A millennium monster is born
EditorialA millennium monster is born
The English have invented a new disease. It is called dangerous severe person-ality disorder or DSPD for short. Perhaps it is no surprise that the Englishhave invented a new disease, the Americans do it all the time if we are tojudge by the exponential growth in the number of diagnoses listed in theDSM series. Please note, however, that it is the English who have inventedthis new disease; so far it has not spread to other parts of the United Kingdom.Another unusual feature is that this disease was invented by politicians. Atthe end of last year, the English Home Office issued a consultation documentabout the management of individuals suffering from this new disease (HomeOffice, Department of Health, 1999). Proposals included a whole new devel-opment of institutions which would be neither prisons nor hospitals, but a‘third way’, and special legal provisions for detaining the sufferers from the dis-ease against their wishes, even if they had not committed an offence because,by definition, they would be dangerous individuals.
Strangely the politicians already have a lot of information about this dis-ease, even though ‘decisions on the direction of policy development for man-aging dangerous people with severe personality disorder cannot be delayeduntil the outcomes of conclusive research are known’. The Home Office esti-mates that there are ‘just over 2000 people who would fall into this group inEngland and Wales’, over 98% of whom are men and mostly in prison orsecure hospitals. In an appendix to the Home Office document we are toldthat there are 1422 adult male sentenced prisoners suffering from this condi-tion in prisons in England and Wales – these are prisoners diagnosed in arecent survey using SCID II as suffering from antisocial personality disorderwho also had 6+ risk factors for recidivism. A further 400 male patients aredetained on court orders under the English legal category of ‘psychopathic dis-order’ in secure hospitals and ‘it is estimated’ (how, we are not told) that thereare a further 300–600 such individuals in the community. The Home Officealso seems to know that £89 million a year (not £90 million you will berelieved to learn) is ‘being spent on the 1800 DSPD individuals in detention’.
Most readers will be aware that antisocial personality disorder is an unsatis-factory diagnosis based partly on criminal history, so adding risk factors for
Criminal Behaviour and Mental Health, 10, 73–76 2000 © Whurr Publishers Ltd 73
CBMH 10.2 1st Proof 8/6/00 4:08 pm Page 73
recidivism to it is tautology. British readers will also be aware that the legalcategory ‘psychopathic disorder’ does not correspond to any one clinical diag-nosis: patients in this category have a variety of DSM axis I & II disorders.
Having identified this new disorder (without waiting for the researchwhich is called for in the document) the Home Office spells out its urgentobjectives: ‘better protection for the public from dangerous severely personali-ty disordered people’. Is this a diversionary tactic? Certainly the number ofhomicides in Great Britain is rising but the proportion of those attributable tomentally disordered offenders (about 80 per annum) is falling (Taylor andGunn, 1999).
How on earth did we get into this mess? Some responsibility has to be laidat the door of the medical profession and some of the impetus is political inthat new panics about folk devils (dangerous criminals) are sweeping throughthe western world.
The medical responsibility begins with philosophy and moves to attitudesand then practical matters. The philosophical point is that in psychiatry wehave been too ready to play the disease game. I have already alluded to thesomewhat ludicrous expansion of new diseases within DSM. The disease gameinsists that suffering has nothing to do with the medical profession, indeedmay not really be legitimate, unless it can have a syndromic name attached toit. Disabilities, suffering, distress have to be justified in terms of ‘it’s not hisfault, he’s suffering from a disease’ and do not seem to be acceptable as mattersof medical concern in themselves. Presumably this is due in part to anextremely high valuation of autonomy and self-determination. It may also bedue to reification of the concept of disease.
Diseases are not real things in the way that people are real things. They areconvenient, abstract concepts that imply correlations between the phenome-na which are said to be the symptoms of the disease. Such disease conceptshave proved powerfully useful in branches of medicine in which physicalpathology has been rapidly elucidated in the 20th century. For psychiatry norapid elucidation has been forthcoming and, indeed, in psychiatry pathology isstill probably better understood in psychological terms rather than in physicalterms. As psychological features are subjective this leads to considerable unre-liability. Unreliability between observers does not, however, mean that theproblems complained of and/or observed are any less distressing, dysfunctionalor life threatening.
Attitudinal and practical issues follow from these philosophical ones. In aworld where most people are thought to be the architects of their own down-fall, where scapegoating and witch-hunting are part of the ground rules of life,it is not surprising that both lay people and doctors believe that very highthresholds need to be employed to excuse anyone on the grounds of psycho-logical dysfunction. Indeed, even although the concept of excuse is not articu-lated very loudly, it seems to underlie the fear that people have about theintervention of psychiatry after some terrible antisocial act has occurred.
74 Editorial
CBMH 10.2 1st Proof 8/6/00 4:08 pm Page 74
Neither lay people nor medical professionals are very keen on dealing withpeople whom they regard as blameworthy and, although the threshold variesbetween observers, most people use a concept of ‘responsibility’ to distinguishbetween those whom they wish to blame and those whom they wish toexcuse, partially or fully.
This question has been debated previously within the pages of this jour-nal (Gunn, 1999; Schanda, 1999; Prins, 2000). In that debate I previouslyraised the matter of resources, which seems to me to be the variable thatmust never be forgotten. If more psychiatrists, more nurses, more hospitalbeds were available then attitudes would probably be affected. The rationingwhich has to occur within any limited service will draw on attitudes andphilosophical concepts to determine who will have privileges and servicesand who will not, and the thresholds for those services will vary accordingto the availability.
What has all this got to do with DSPD? Everything. At first it was difficultto understand what the politicians meant by the concept of DSPD at all, thenit became clear that as it was generated by politicians rather than medical sci-entists it did not map on to current medical concepts at all. It was quicklyshown that if it was taken north of the English/Scottish border the new jargonwas dropped and the concept unpacked to reveal the heterogeneous collectionof individuals who have either committed or who were thought to be going tocommit serious violence or serious sexual offences (especially on children)and who have some identifiable psychological problems. Put like that, it ismuch easier to understand (a) the political panic about this group and (b) thecontribution which psychiatry may or may not be able to make.
It is undoubtedly true that individuals who have seriously offended in theways just described and who have significant psychological problems havebeen very much at the bottom of the heap for available resources, so much sothat even patients who are clearly psychotic are not receiving adequate, oreven, sometimes, any attention. Indeed, it is my strong suspicion that we arenow failing to diagnose psychosis in a large number of individuals who havecommitted terrible offences, partly for unconscious reasons but also becausewe are now dumbing-down our assessment procedures. Such individuals maybe a substantial proportion of the ‘DSPD’ population.
In England and Wales we now have an uphill struggle on our hands. Weneed to persuade our Home Office not to drop its interest and particularly itsresource allocation for a needy, hitherto neglected, group of patients, but atthe same time to back away from new types of prison and new preventivedetention laws and focus instead on the well-tried arrangements we alreadyhave. It is true that our prisons can do with more psychiatric resources. Wehave secure hospitals that also need more resources. We need more and betterdoctors and nurses working in this field. We need more specialization withinour psychiatric services. We certainly do not need new and restrictive laws.The United Kingdom has many laws that can be used imaginatively and effec-
Editorial 75
CBMH 10.2 1st Proof 8/6/00 4:08 pm Page 75
tively if we have sufficient and appropriate staff. Politicians, many of whomare lawyers, rush to legislate; we need them to provide resources instead.
The purpose of this editorial is to see whether readers recognize any of theprocesses I am describing within their own jurisdictions and whether they cangive the British government any advice about how to tackle an undoubtedmedico-political problem without getting trapped in large expenditure on‘third ways’ or at loggerheads with human rights watchdogs. This proposal hasreceived a resounding thumbs-down from the mental health professions andtherefore cannot move smoothly ahead. What can be done for a forgottengroup of people who are small in number, disliked by most people and whomay well take out their frustrations on other citizens?
John GunnEditor
References
Gunn J (1999) Editorial comment: The Ashenputtel principle. Criminal Behaviour and MentalHealth 9: 205–206.
Home Office, Department of Health (1999) Managing Dangerous People with Severe PersonalityDisorder. London: Home Office, DoH.
Prins H (2000) Letter to the Editor: A limited response to Hans Schanda. Criminal Behaviourand Mental Health 10: 66–68.
Schanda H (1999) The Ashenputtel principle in modern mental health care. CriminalBehaviour and Mental Health 9: 199–204.
Taylor PJ, Gunn J (1999) Homicides by people with mental illness: myth and reality BritishJournal of Psychiatry 174: 9–14.
76 Editorial
CBMH 10.2 1st Proof 8/6/00 4:08 pm Page 76
