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Responding to Violence, Suicide, Psychosis and Trauma

Dangerous people with severe personality disorder British proposals for managing them are glaringly wrong—and unethical

BMJ. 1999 October 30; 319(7218): 1146–1147.

PMCID: PMC1116939
Copyright © 1999, British Medical Journal

Paul E Mullen, professor of forensic psychiatry
Monash University and Institute of Forensic Mental Health, Victoria, 3084 Australia

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 public 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.5They 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.

Department of Health; Home Office. Managing dangerous people with severe personality disorder. London: Home Office; 1999.
Kury, H; Ferdinand, T. Public opinion and punitivity. Int J Law Psych. 1999;22:373–392. [PubMed]
Hare, RD. The Hare PCL-R: some issues concerning its use and misuse. Legal Criminol Psychol. 1998;3:99–112.
Quinsey, VL; Harris, GT; Rice, ME; Cormier, CA. Violent offenders: appraising and managing risk. Washington, DC: American Psychological Association; 1998.
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. [PubMed]
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 neighborhoods. Arch Gen Psych. 1998;55:393–401. [PubMed]
Eastman, N. Public health psychiatry or crime prevention? BMJ. 1999;318:549–551. [PubMed]

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