In Reply:These letters offer the opportunity to update readers of Psychiatric Services on the government's proposal in England and Wales for new mental health legislation. The most controversial aspects of the proposal involve changes to the definitions of mental illness and treatment that would permit the involuntary commitment of "dangerous persons with personality disorders" for whom there is no prospect of successful treatment. In effect, the mental health system would become a detention service for people without serious mental illnesses who are predicted—with uncertain accuracy—to be dangerous to the public.
I noted in my column that the legislation was being reviewed by a special joint parliamentary committee, and the committee's report has been released (1). The committee strongly rejected the government's proposed approach, concluding that persons who are thought to be dangerous as a result of severe personality disorders should be dealt with by means other than mental health legislation. In addition, the committee recommended raising the threshold for the risk of harm necessary for commitment and adding requirements that a beneficial treatment be available and that the person have significant impairment in decision-making abilities. In its comments, the committee echoed the concerns of British psychiatrists and others regarding the illegitimacy of turning to the mental health system to solve the problems of crime.
Dr. Adetunji and his colleagues suggest that the procedural safeguards built into the Mental Health Act should remove any concerns that patients' rights will be abused. But they mistake the real issue here. No matter how stringent a set of procedures, if the criteria being applied through the process are fundamentally flawed—as is the case with the draft bill—there is no procedural remedy. If the law allows an essentially untreatable psychopath to be detained in a psychiatric facility solely for the protection of public safety, all that any review process can do is to ratify that decision. (By the way, perusal of the source Dr. Adetunji and colleagues cite for their figures on the frequency with which patients invoke review by mental health tribunals indicates that there were actually 42,211 persons committed involuntarily in 1996-1997, including those committed after admission and a small number committed to secure nursing facilities, and that only 7,473 hearings were actually held.)
In their letter Dr. Mathews and colleagues want to defend the legitimacy of "dangerous severe personality disorder" as a diagnostic concept. But their reliance on "societal metamorphosis" as a basis for developing psychiatric diagnoses is hazardous. As in this case, it would permit the government to declare whomever it chooses as mentally ill and subject to hospitalization. With regard to treatability of dangerous people with severe personality disorders, the comparison to borderline personality disorder—for which there are evidence-based treatments—is inapposite, as is the comparison to mental retardation, in which institutional care is directed at meeting persons' basic needs—hardly the case here. The fact remains that DSPD is a category defined more by criminal behavior than by signs or symptoms of mental disorder and that there is no evidence that unwilling persons with this label benefit from attempts at "treatment."
The report of the joint parliamentary committee suggests that England may be pulling back from a perilous attempt to use the mental health system for overt social control. But the story has not yet ended, and the denouement will tell the tale.