When hospital is a prison
The government wants to change the Mental Health Act so that
some persistent offenders can be locked away without charge. Ben Goldacre says
it is worrying when diagnosing illness is politically motivated
The Guardian July 16, 2002
When I hear the phrase "political psychiatric diagnosis", I start thinking about
Soviet dissidents, dosed up on thioridazine, being physically restrained on
lock-up wards. I like to think I would have had nothing to do with that kind of
business, because I went into psychiatry to help people, not to be a jailer.
I know from experience that there are occasions, regrettably, when I need to
admit someone to a psychiatric ward against their will. I am comfortable doing
that, because I work in a culture where it is only done in the patient's best
interests, and there are checks and balances to prevent a compulsory admission
being done inappropriately. But I am well aware that the powers given to
psychiatry are open to abuse, and that in Soviet Russia, for example, they were
horrifically abused.
Now, in an atmosphere of tabloid panic about the dangers posed by persistently
violent psychopaths, the government is proposing a change in the Mental Health
Act, against the prevailing opinion of almost all psychiatrists and
mental-health interest groups. Now they want us to lock up the kind of
persistent, remorseless offenders who most psychiatrists, to put it crudely,
would see as more bad than mad, and who are often considered to be incurable.
There has always been an argument in psychiatry about whether disorders of
personality should have the same status as mental illnesses such as
schizophrenia or manic depression. A personality disorder is a lifelong and
ingrained pattern of maladaptive behaviours that are damaging to the individual
or others around them. There are many more types of personality disorder defined
in the diagnostic manuals than simply the antisocial: anxious-avoidant,
borderline, dependent, histrionic, narcissistic, obsessive, paranoid and so on.
The traits include aggression, alcohol and substance misuse, anxiety,
depression, deliberate self-harm, eating disorders, suspiciousness,
preoccupation with routine, displaying a lack of emotion or remorse,
hypersensitivity to criticism, constantly seeking approval, dependence on
others, deceitfulness, bullying and disregard for others.
A diagnosis usually has to include at least three traits or behaviours, but
personality disorder is a fairly flexible category, and could be broadly
applied. When you're at medical school studying psychiatry and they teach you
about personality disorder, you all sit in the pub afterwards discussing which
ones your friends and ex-partners have got. That's because they're all about the
kind of person you are, and changing someone's personality is a very difficult
business. We are pretty good on schizophrenia or depression, but there's often
not a lot that psychiatrists can do for people with personality disorders.
The government is unhappy with this, particularly when it comes to people with
antisocial personality disorder. These are often inveterate and remorseless
criminals, such as Michael Stone, who in 1996 murdered Lin Russell and her
six-year-old daughter Megan. He had been left at large to commit the crime
because his antisocial personality disorder was considered untreatable, so he
could not be detained under the Mental Health Act.
Generally, people like this end up in the prison system because they keep
committing crimes and they keep getting caught. But sometimes they are at large,
even though everyone knows they are a danger, because they've been recently
released from prison, or because they've not been caught. Now the government
wants psychiatrists to start impounding them on grounds of risk alone. They have
rewritten the Mental Health Act completely, putting the emphasis on risk first
and patients second, and producing a bill which reads like a piece of
public-order legislation. They want psychiatrists to lock up these people - with
no criminal charge, mind - on the grounds that they might commit a crime later.
Throughout the whole process there has been a feeling of remarkable disregard
for the opinions of psychiatrists. The most bizarre move came in 1999 when, in a
green paper, the government took it upon itself to invent a psychiatric
diagnosis: "dangerous and severe personality disorder" (DSPD), referring to
people with severe personality disorders who pose a serious risk to the public.
They even managed to come up with a figure for the number of people currently in
the prison system who had this disorder: 1,422. An impressively precise figure
for their own psychiatric diagnosis, which had no diagnostic criteria, no legal
or psychiatric grounding, and almost no research base.
When politicians start inventing psychiatric diagnoses, I get nervous. And when
they start defining mental illnesses by the effects that the individual has on
our society, rather than the problems of the patient, I start thinking about
Soviet Russia.
I'm not claiming that locking up persistently violent criminals without charge
on the grounds that they might offend later is as bad as locking up political
subversives. What I am saying is that the political motive is the same. Plenty
of political subversives were sent to Stalin's labour camps; they were only
given psychiatric diagnoses and shipped off to the secure hospitals, such as the
famous and dreaded Serbsky Institute, when they represented an embarrassment to
the state.
The first famous case of political abuse in Soviet psychiatry was Major-General
Grigorenko, a senior political figure who turned his back on the system, and
became interested in the persecution of the Crimean Tartars by Stalin, to the
point of acting as a character witness in their trials. Rather than send him to
prison, Stalin preferred to have him declared insane and committed to Serbsky.
Here, doctors concluded that he was suffering from a "pathological paranoid
development of the personality with the presence of reformist ideas". The die
was cast.
The attempts by Soviet psychiatrists to render criminal subversive acts
psychiatric were so ham-fisted they were almost comical. Among their symptoms of
schizophrenia were "reformist delusions: a belief that an improvement in social
conditions can be achieved only through the revision of people's attitudes, in
accordance with the individual's own ideas for the transformation of reality";
and "litigation mania: a conviction, which does not have any basis in fact, that
the individual's own rights as a human being are being violated and flouted".
Textbooks and manuals abounded with astonishing quotes: "Ideas for truth and
justice most commonly arise in personalities with a paranoid structure."
Similarly, an official Chinese encyclopaedia on police work from 1990 lists the
three types of people to be taken into police psychiatric custody. One category
was defined as "those commonly known as 'political maniacs', who shout
reactionary slogans, write reactionary banners and reactionary letters, make
anti-government speeches in public, and express opinions on important domestic
and international affairs."
I am not worried about remorseless and unremitting criminals being dealt with
very robustly, but I'm not sure that, for many of them, medication should play
any part. It is appropriate that someone who is acutely mentally ill, who is
agitated and distressed and injuring themselves and other people, is sedated.
But the same may not be true for persistent offenders.
Relentlessly violent people are a problem, but they are not necessarily a
psychiatric one. Professor Lunts, a Soviet psychiatrist, claimed that any
criminal act, by virtue of its criminality and deviation from social norms
alone, merited a psychiatric approach. He justified his claim by saying that
under socialist conditions there were no social causes for crime; and more than
that, it was only under capitalism that we could observe "social disharmony"
leading to crime. Perhaps part of the problem is that neither we nor the Soviets
ever wanted to admit the significant role that social factors play in deviant
behaviour, and so to save ourselves the embarrassment, we have pathologised it.
Whatever its motivation, the problems of the bill go beyond the politicisation
of psychiatry, because its proposals are simply impractical. Research at the
Maudsley hospital in London, one of the country's leading psychiatric research
institutes, shows that - even with the best predictive tools in the world - you
have to lock up six potential offenders (without criminal charge) to prevent one
person committing a crime.
And not only does the bill give scant mention of extra resources to serve these
new customers - it also diverts them from patient care, which then suffers.
"It's a ludicrous aberration, dreamed up by the Home Office, that diverts money
from psychiatry into so-called security," says John Gunn, professor of forensic
psychiatry at the Maudsley. "They interfere with treatment programmes in secure
units, and divert staff from groups and therapeutic interventions into security
duties, and limit access to members of the opposite sex and children, making
things less safe in the long run."
Governments interfering with psychiatry and inventing their own diagnoses is a
dangerous and wrong-headed business. Using psychiatry as an agent of social
control is unacceptable. We may have something to offer the rehabilitation of
relentless and remorselessly violent offenders. But if you want jailers, you can
say so openly, and you can pay for them.
• Ben Goldacre is a psychiatrist working in London.
Source:
http://www.guardian.co.uk/health/story/0,3605,755922,00.html
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