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The problematic status of personality disorder

Although the overwhelming concern of the State and psychiatry during the nineteenth century was lunacy, ‘moral insanity’ was also described: The moral principles of the mind are strongly perverted or depraved; the power of self government is lost or greatly impaired and the individual is found to be incapable not of talking or reasoning upon any subject proposed to him, but of conducting himself with decency and propriety in the business of life.

The concern of the State to utilize medical facilities to control bad behaviour (in the absence of formal evidence of psychosis) continued in the twentieth century. The current legal definition of psychopathy appears under the Mental Health Act 1983 as: ‘a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned’.

A problem with this legal definition is that it maps poorly onto preferred professional ones. For example, the use of the term ‘psychopathy’ in law approximates to those of ‘anti-social personality disorder’ and ‘dissocial personality disorder’ codified by the American Psychiatric Association (1994) and the World Health Organization (1992) respectively. However, to complicate matters, there is a strong clinical tradition of using the word ‘psychopath’ to describe people who show overlapping symptoms of three types of personality disorders (anti-social, histrionic and narcissistic) (Cleckley 1941; Hare 1991). Some but not all of those with this clinical profile become criminals.

While early psychiatry was concerned with ‘moral insanity’, during the twentieth century it began to codify many other types of personality disorder. By 1994 the American Psychiatric Association described ten types, in addition to that of anti-social personality disorder (the approximate conceptual legacy of ‘moral insanity’). One of these, ‘borderline personality disorder’, is used commonly to describe female prisoners who are emotionally unstable. Personality disorder has been controversial for a number of reasons:

•As its etiology is not known, it is described tautologically by its symptoms and its symptoms are accounted for by the existence of the disorder; (For example, a man is deemed to be psychopathic because he rapes children. His raping of children is then explained by his psychopathy.)

•In the light of the above, it is impossible to disentangle attributions of personal abnormality from social deviance (Blackburn 1988; Parker et al. 1995);

•The types of personality disorder described are not coherent and separate but overlap in clinical presentations, undermining the validity of specific diagnoses (Pilgrim 2001);

•Mental health professionals are divided about the treatability of personality disorder. By definition, personality refers in the professional discourse to stable and unchanging personal attributes. If a personality is deemed as abnormal then it cannot (or would not be expected to) change. Despite this there is some empirical evidence that people with a label of psychopathy offered psychological interventions reoffend less often than those untreated. Thus psychopathy itself may not be treatable but the overall probability of specific offending behaviours may be reduced in groups of patients with the diagnosis. This then leads to a further challenge; risk prediction in particular cases is difficult to estimate.

The logical and empirical vulnerability of any diagnosis of personality disorder created by these doubts and criticisms has not deflected either the State or some parts of the psychiatric profession from using personality disorder as a legitimate notion and rationale for social control. Such a continuing political and professional imperative has been divisive though. Mainstream psychiatry showed evidence of wanting to reject psychopaths as patients worthy of their attention but personality disorder is part of the bread and butter work of forensic psychiatry. In the Mental Health Act 1983 a treatability clause had to be inserted to prevent open-ended professional decision making. It stated that if a patient is suffering from psychopathic disorder, treatment must be likely to ‘alleviate or prevent a deterioration’ of the person’s condition. Why is psychiatry divided in this way about psychopathy? The answer may lie in the lack of responsiveness to treatment of this group of patients.

However, this could well apply to other psychiatric diagnoses. For example, the limited success of treating ‘schizophrenics’ with major tranquillizers has not led to mainstream psychiatry wishing to diminish its contact with this group. A more plausible explanation is connected to changes in segregative control. Ramon (1986) traces the change in the psychiatric stance towards psychopathy to developments in psychological approaches just after the Second World War. Then, soldier patients showing evidence of psychopathic disorder began to be treated in therapeutic communities.

The move away from segregative control in mainstream psychiatry meant that the method to control antisocial behaviour became less feasible. Forensic psychiatry in contrast still had the segregative means to effectively manage such deviance. Indeed, it seems to be that the precondition of the psychiatric detention of this group is governed by the demands of security and public threat, rather than mental state. As patients who have committed offences, they are likely to be detained for a period at least commensurate with the gravity of their offences (Norris 1984; Peay 1989). This is true also for those who have committed minor offences. An American study, using a large random sample of misdemeanor defendants, found that those with a psychiatric history were ‘criminally sanctioned more severely than defendants without psychiatric records, and defendants with relatively extensive psychiatric records were even more severely sanctioned’ (Hochstedler-Steury 1991: 358). The importance of the psychopath to forensic psychiatry (in both numerical and therapeutic terms) illustrates the two systems which it tries to bridge. By definition, the mentally disordered offender qualifies for entry into both the criminal justice and mental health systems. This raises particular dilemmas and questions which arise out of a merging of two types of deviance, criminality and mental disorder. Explicitly stated, should individuals be dealt with in the system designed to deal with the criminal aspects of their behaviour (i.e. in prison) or should they be treated for their mental disorder in hospital? This can be framed in terms of the psychiatrization versus criminalization of deviance.

The arguments for psychiatrization are made on the grounds that hospitalization of mentally disordered offenders is less stigmatizing and hospital treatment benefits patients more than do prisons. Prisons are unable to provide the environment or range of treatments that a health care regime can (Abramson 1972). A policy initiative stemming from this reasoning is the diversion of mentally disordered offenders from custody projects, which are also informed by the prevailing ethos of community care. Others (Monahan 1973; Fennell 1991) see psychiatrization as resting on dubious grounds. They point out that mental hospitals are not stigma free. Arguably, in Britain the association of the high-security hospitals like Ashworth and Broadmoor with notorious serial killers and gangsters means that they are far more stigmatizing than prisons. There are also doubts over whether medical treatment regimens are superior. As discussed earlier, those labelled as psychopathic make up a significant proportion of those in high-security hospitals, yet there is little evidence to suggest there is an effective treatment for antisocial behaviour. There is evidence that the ‘recidivism’ rate is lower for those coming out of hospital, i.e. discharged forensic patients are less likely to reoffend than mentally disordered offenders discharged from prison (Fennell 1991). But this may be attributed to the conservative discharge policies of hospitals, which are driven as much by ‘security’ considerations, as it is to changes in the mental state of patients. ‘Psychopaths’ in high-security hospitals receive longer periods of detention, on average, than their counterparts in mainstream prison provision, as judged by equivalent index offences (Peay 1989). There are two main arguments underlying a criminalization position. The f irst relates to a moral and philosophical argument that both those who are designated mentally ill and those who are not should be treated as humanely as possible. That is, poor and ‘brutalizing’ conditions should not exist in either the prison or mental health systems (Monahan 1973).

Reforming the prison system has also been argued for on pragmatic grounds. Fennell (1991) suggests that there will always be situations which do not permit the rapid transfer of mentally disordered offenders out of the prison system. Prisoners may not meet the legal criteria for transfer or transfer cannot be arranged quickly enough. Additionally, transfer may not always be the fairest option for prisoners. Sentences are often suspended for prisoners who spend time in hospital and recommenced if a person is transferred back to prison. (That is, there is no remission for the period that they have been treated as patients, and so their detention is extended beyond their sentence.) Moreover, increased diversion into psychiatric facilities is unrealistic, given the burden on existing facilities and the failure to rapidly develop more regional secure facilities. Fennell argues for a proper legal framework for psychiatric treatment in prisons to be established as a means of improving the standard of care that is currently provided.

One policy option which tries to bridge the gap between these two positions was proposed by the Tumin Report (Woolfe and Tumin 1990). This suggested that adequately staffed psychiatric intensive care wards in the NHS be provided inside prisons. The debates about the comparative merits of criminalization and psychiatrization are mainly in relation to different ways of controlling and containing offender patients. Alongside these arguments about which institutional structures (penal or health care) should take precedence is evidence of a coalescence of systemic processes. There has been a shift in both mental health and criminal justice facilities towards an actuarial policy (Armstrong, 2002). The latter refers to the emphasis on risk calculation as the main procedural guide to professional action in both systems.

While the penal system traditionally aimed to rehabilitate offenders, and the psychiatric system aimed to treat patients, in recent years both aspirations have been displaced by an emphasis on risk minimization. Treatment and rehabilitation in different ways are orientated towards the reform of the deviant individual. Treatment ideologies, prior to the emergence of actuarilism, had, to some extent, influenced rehabilitation interventions for some prisoners. For example, prisons have contained therapeutic communities as part of their rehabilitative strategy. By contrast, actuarial management is more about using diagnostic methods to efficiently contain the social threat of groups of deviant people, wherever they are contained. Both actuarial and treatment approaches are examples of how mental health assessments and interventions have permeated the criminal justice system.

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