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

Tuesday July 16, 2002
The Guardian

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.

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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.