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Detention of potentially dangerous people
EDITORIAL
THE LANCET Volume 352, Number 9141
Detention of potentially dangerous people How should a person with an untreatable mental disorder who is a potential danger to the public be supervised? This question has arisen from a recent case of unprovoked murder in the UK in which, despite his threats to kill people and his requests for hospital admission, the convicted person had not received secure-hospital care because of the view that his antisocial personality disorder was untreatable. An inquiry has been launched. The Mental Health Act is also being reviewed comprehensively, and the psychiatric profession is clearly apprehensive about the implications of possible reforms. Clarification is needed on many issues. What constitutes personality disorder, a term that does not appear in the Mental Health Act, which provides for the compulsory treatment of people with mental disorders? How low a probability of alleviation or prevention of deterioration of the disorder should be taken as treatability? Since personality disorder is incurable, are there resources for indefinite followup? Should personality disorder be “medicalised”? Or are people with antisocial personality disorder more appropriately supervised by the criminal rather than the health services? Their “treatment” could surely just as well be regarded as rehabilitation. Can the UK look to other nations for leads on how to deal with this group of people? Several countries in continental Europe do not put the supervision of those with antisocial personality disorder into the mental-health system. In Switzerland and Germany, for instance, such people who have committed offences are followed up under security measures for an indeterminate period, with or without a preceding prison sentence. During this time they take part in a social therapy programme. The Netherlands, too, has a range of security measures under which people can be detained indefinitely; at one end of this range are very-high-security units. This system does not cover “pre-offenders”. In most cases, though, the first offence is not a serious one. Past offences are by far the best predictor of dangerousness. Risk assessment is central to the selection of people for compulsory treatment. Unfortunately, although it can be improved, risk assessment is an inexact science. Predictions for THE LANCET • Vol 352 • November 21, 1998
individuals are more difficult than for groups, and prediction of when an offence might be committed beyond the near future is more a guess. Reviews have indicated that the false-positive rate for prediction of violence is double the true-positive rate, so safety of the public should be weighed carefully against the rights of potential offenders. False-negative predictions are the great fear. Although negligence is unacceptable, the fact that risk assessment is not foolproof must be recognised. Society should not be too eager to pin liability on individuals when things to wrong. When a jury in North Carolina found against a psychiatrist whose patient, a law student, sued him for not preventing him from going on a killing spree, the reaction of psychiatrists was to question whether they would agree to work with the most difficult patients. Whether responsibility for mishaps among an unreliable and non-compliant population whose disorder is lifelong and not easily improved to any extent should be individual or corporate ought to be reviewed carefully. Although one view is that officers in the criminal system are as able as mental-health professionals at assessing risk of potential violence, the latter should manage this difficult group of people because treatable and untreatable disorders commonly coexist. The 1983 revision of the 1959 Mental Health Act moved the emphasis from protection of the public from mentally disordered people towards protection of the individual from society, and society ought to decide how much it wants the pendulum swung back in the other direction. The scale of the problem should be kept in perspective. In the UK, the prevalence of psychosis is about four per 1000 adults. Serious violence is even rarer. 600–700 homicides are committed each year, but a confidential inquiry over 33 months showed that only 39 were committed by people who had been in contact with the specialist mental-health service in the preceding year. Finally, whatever reforms are introduced, they should not be brought in without an adequately controlled study, for there is no evidence that one system is better than another.
The Lancet 1641
THE LANCET Volume 352, Number 9141
Detention of potentially dangerous people How should a person with an untreatable mental disorder who is a potential danger to the public be supervised? This question has arisen from a recent case of unprovoked murder in the UK in which, despite his threats to kill people and his requests for hospital admission, the convicted person had not received secure-hospital care because of the view that his antisocial personality disorder was untreatable. An inquiry has been launched. The Mental Health Act is also being reviewed comprehensively, and the psychiatric profession is clearly apprehensive about the implications of possible reforms. Clarification is needed on many issues. What constitutes personality disorder, a term that does not appear in the Mental Health Act, which provides for the compulsory treatment of people with mental disorders? How low a probability of alleviation or prevention of deterioration of the disorder should be taken as treatability? Since personality disorder is incurable, are there resources for indefinite followup? Should personality disorder be “medicalised”? Or are people with antisocial personality disorder more appropriately supervised by the criminal rather than the health services? Their “treatment” could surely just as well be regarded as rehabilitation. Can the UK look to other nations for leads on how to deal with this group of people? Several countries in continental Europe do not put the supervision of those with antisocial personality disorder into the mental-health system. In Switzerland and Germany, for instance, such people who have committed offences are followed up under security measures for an indeterminate period, with or without a preceding prison sentence. During this time they take part in a social therapy programme. The Netherlands, too, has a range of security measures under which people can be detained indefinitely; at one end of this range are very-high-security units. This system does not cover “pre-offenders”. In most cases, though, the first offence is not a serious one. Past offences are by far the best predictor of dangerousness. Risk assessment is central to the selection of people for compulsory treatment. Unfortunately, although it can be improved, risk assessment is an inexact science. Predictions for THE LANCET • Vol 352 • November 21, 1998
individuals are more difficult than for groups, and prediction of when an offence might be committed beyond the near future is more a guess. Reviews have indicated that the false-positive rate for prediction of violence is double the true-positive rate, so safety of the public should be weighed carefully against the rights of potential offenders. False-negative predictions are the great fear. Although negligence is unacceptable, the fact that risk assessment is not foolproof must be recognised. Society should not be too eager to pin liability on individuals when things to wrong. When a jury in North Carolina found against a psychiatrist whose patient, a law student, sued him for not preventing him from going on a killing spree, the reaction of psychiatrists was to question whether they would agree to work with the most difficult patients. Whether responsibility for mishaps among an unreliable and non-compliant population whose disorder is lifelong and not easily improved to any extent should be individual or corporate ought to be reviewed carefully. Although one view is that officers in the criminal system are as able as mental-health professionals at assessing risk of potential violence, the latter should manage this difficult group of people because treatable and untreatable disorders commonly coexist. The 1983 revision of the 1959 Mental Health Act moved the emphasis from protection of the public from mentally disordered people towards protection of the individual from society, and society ought to decide how much it wants the pendulum swung back in the other direction. The scale of the problem should be kept in perspective. In the UK, the prevalence of psychosis is about four per 1000 adults. Serious violence is even rarer. 600–700 homicides are committed each year, but a confidential inquiry over 33 months showed that only 39 were committed by people who had been in contact with the specialist mental-health service in the preceding year. Finally, whatever reforms are introduced, they should not be brought in without an adequately controlled study, for there is no evidence that one system is better than another.
The Lancet 1641