Dr. M.T. Haslam

Chairman, Society of Clinical Psychiatrists

I am replying as Chairman of the Society of Clinical Psychiatrists, which group has had particular interest in these matters, (I enclose our brochure for information) and is a group which represents some 250 senior psychiatrists and acts, to a large extent, as a ginger group in the profession of counter-balancing the more orthodox views which the Royal College of Psychiatrists perforce has to express.

PREAMBLE

In looking at the issue of personality disorders one has to remember that the 1959 Mental Health Act quite clearly delineated psychopathic personality, the definition of which in my past experience provided a useful guide to the necessary at times compulsory detention of such individuals for hospital care.

The 1983 Act in our experience has confused things rather than helped and has created the situation with which we now have to grapple, mainly that many individuals who ought to be in hospital or som form of detained premises are no longer able to be so since the 1983 Act had the rather quaint idea about treatment.

The care and management of an individual who is not well enough to be at large in the community is, to our mind, treatment by any other name. To suggest that because it is not possible to psychopathy by current methods is to ignore the fact that it is not possible either to cure many types of cancer, Alzheimer's disease, multiple sclerosis and a host of other conditions within the medical and surgical textbooks, yet we do not deny these people care. It is the compulsory element perhaps which caused the unrealistic do gooders of twenty-five years ago to influence the way the new Act was worded. We would suggest that psychopathic personality (and sociopathic personality was also used) as used in the United Kingdom was a useful definition and the fact that they did something slightly different in the United States is really of no relevance. Such individuals are different from other people generally subsumed under the title of personality problems, such as obsessional neurosis, paranoid, alcohol or drug abusers etc. though some may overlap. To suggest however that obsessional personality should come under the same heading as what we are calling psychopathy is quite obviously nonsense.

The definition psychopathic personality quite clearly referred to individuals who appeared to have little social awareness, found great difficulty in making bonded relationships, did not seem to learn from experiences and were often unaware of others' distress which they were causing. These and a number of other features produced a syndrome which, in the view of many of us, is quite likely when research becomes more sophisticated to prove to be a developmental abnormality on the lines of many other developmental abnormalities and is much more likely to be treated by genetic means eventually, or by biochemical modification of whatever it is that is causing this disability rather than by the "talking cure" which, of course, has been in retreat ever since Freud. We must not forget malaria, at one time, was believed to be caused by evil spirits in the Nile valley and that quinine frightened the evil spirits away. I do not think that we are much further on with psychopathic personality.

This being the case, it is necessary to see in what way such sufferers differ from the rest of the population; primarily they differ in terms of dangerousness and unpredictability and it is for this reason and this reason only that the need for possible compulsory care needs to be considered.

PLACEMENT

The question arises therefore and has been addressed in the policy document as to where such people, when they need such are, are best cared for. We would suggest that an area of expertise needs to be developed to deal with such individuals and that an atmosphere of positiveness needs to be inculcated into the staff and the unit. It is difficult to do this when such sufferers are planted in ones and twos on other wards where they are disruptive and often frightening to other individuals who are in hospital, for example the puerperal depression, or severe anxiety reactions. We would suggest therefore that despite the difficulties encountered in putting a large number of these people together (such private hospitals as Stockton Hall near York seem to be producing a good model of care and are indeed the sort of places currently taking such patients if they come through the courts) it would seem to demand that specials units be set up dotted around the country in appropriate areas, much as are other units such as the prisons and other types of specialist psychiatric units, such as those treating drug addictions.

The essence is overkill in terms of staff numbers. Such units would be expensive but I suspect, if properly costed, not half as expensive as is the current situation in terms of people being sued and suing.

We would agree that research into causation is still inconclusive. To go in detail into the early history and upbringing of such patients many of us would feel is likely to be counter-productive. We should be looking at DNA, studying brain structure with CAT scans and the like if we are to get far with this particular group. There are however clues as to causation, which are multifactorial, for example non-specific EEG abnormalities. There is quite associated limitation of intellectual development, though by no means always, and there are quite often chromosomal abnormalities. All these we suggest are pointers.

The document states that it would strengthen existing legislation so that dangerous severely personality disordered people would not be released from prison or hospital while they continued to be a risk to the public. This is the nub of current problems, namely the assessment of risk. Risk assessment is not, in our view, a sophisticated art. It is indeed anybody's guess who might suddenly lose their temper and commit a serious assault or other crime on person or property months ahead from the time of assessment. We do not feel that the present risk assessment programs as contained within the Mental Health Act and newer regulations and guidelines have been particularly productive except in allowing the government to allocate blame to individuals who are doing their best when things go wrong. In the past perhaps psychiatrists were over-cautious in their discharge policies. Certainly the matter has now swung much too far the other way. Unfortunately the experience of looking after unpredictably violent individuals has been lost with the closure of what, in the past, was known as the "disturbed ward". Nursing staff are not happy in such situations and nor are they happy in enforcing treatment for example on an unwilling individual.

CONCLUSIONS

We believe that part of the 1983 Mental Health Act which refers to somebody being likely to benefit from treatment in hospital before they can be detained should be repealed and a new concept of treatment, which includes care and management should be replacing it.

We believe that planning services for such individuals is not as difficult as it is made out. The difficulty arises because of the reluctance of staff at present to get involved in the treatment of such individuals who are notoriously unfulfilling to treat in terms of results. The same of course applies to Alzheimer's disease, but here we have usually pleasant little old ladies and not young tough men liable to hit you. We do not thing that the cause of psychopathic disorder is likely to be found in the immediate future and therefore consensus about the nature of the condition should revert to the 1959 definitions of psychopathic personality which, in fact, worked perfectly well in the majority of cases.

Currently psychiatric units do not have facilities for dealing with unpredictable disruptive individuals. The same applies to those with drug addiction problems. It is totally unsatisfactory that these individuals should be nursed on the same ward as patients with conventional psychiatric illness of the type that normally needs admission such as depression and schizophrenia. Special units are perforce being developed therefore but are mostly in the private sector. Stockton Hall in York is one which we know and where admission is, broadly speaking, because of dangerous unpredictability. However, most cases there have to be admitted through court orders and have committed some criminal act before admission is appropriate. One is surely trying to get people, if possible, before this happens rather than after, though it is difficult to lock somebody up for dangerousness when they have not in fact committed a serious assault. However, this should be left to professionals with experience in the care and treatment of such cases since they are more likely to make good judgements than anybody else.

Addressing therefore the questions which are posed in the document, we consider that, of the policy options listed, a single systematic approach to managing DSPD individuals in special units is the best way forward. We do not think they can be managed effectively within the existing structures and we think that urgency is the word that should be promoted.

SERVICE PROVISION

We suggest that hospitals such as Stockton Hall would be valuable for staff to visit in terms of identifying both the problems and successes which such units have had in their development over the last ten years or so. We note a heavy turnover of staff at Stockton Hall and suggest that this is because of some difficulties with creating job satisfaction in such an environment.

We think that they key to such a unit's success lies in the options which patients have for safe and contained, but physical daily activities, such as gymnastics, swimming etc. and that there needs to be a very high staff patient ratio. Special training particularly for nursing and other staff in contact with these patients is essential. Staff should go on specific training courses before such a unit is opened since we no not feel it is currently well covered within the psychiatric curriculum. We believe that this should come under the Department of Health rather than Prison, Social Services, Home Office or other such departments within government since we believe that this is, in fact, a psychiatric disability. Nevertheless, joint working between departments concerned with compulsory admissions and freeflow between prisons, other psychiatric hospitals and these special units has to be available. Thus we cannot have too high a bed occupancy since there will always be peaks and troughs in admissions needs and, the last thing anybody wants, is to ring up with a patient of this kind and be told there is a waiting list.

Secure perimeters such as exist in the prison service will, unfortunately, be necessary.

STATUTORY REPORTS

It seems to us that all people with relevant skills should have input into the developing of final reports when these are required, but have never seen it as appropriate that what we perceive as medical issues should, in the final analysis, be decided by anybody without medical training. When this does happen then underlying medical conditions, such as brain damage, brain tumour and a host of other rare possibilities are missed.

Outcome measurement will have to be very much long term and it is inevitable that there will be mistakes made with regard to inappropriate discharges from time to time. Society has had to accept this with regard to the closure of many of the psychiatric institutions and it is always a difficult matter to balance. Parole and leave while still under section are to techniques that obviously would need to be available.

We do not believe that outside of the eugenics employed in pre-war national socialist governments such as Germany that prevention is currently a realistic issue. Prevention of recurrence will depend on the assessing skills of those involved in care, but the main success in the past with psychopathic personalities is that determined by age. The older the psychopathic personality the less of a danger he became and this, of course, was absolutely nothing to do with anything anybody did. We need to set rules and not to think that we can play God with situations that are probably pre-natally determined in the vast majority.