One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: (...) the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 185-187 [Access article in PDF] Measuring Moral Identities:Psychopaths and Responsibility Gwen Adshead Doctor Ciocchetti examines the responsibility of psychopaths as a function of psychological capacities operating within relationships. He then argues against the punishment of psychopaths. I have some sympathy with both views, but perhaps argued in different ways, and from different standpoints, based on my clinical experience.Doctor Ciocchetti's offers an unusual account (...) of responsibility as a concept that involves at least two people, and perhaps many more than two; and this I would entirely support. In this sense, responsibility is a transitive and dynamic process that involves not only the personal sense of ownership of an action or thought, but also the attribution of responsibility by others. Moral, when applied to intentions, seems to me to suggest that they are intentions that involve another person and that they are held by an active agent who can make choices about those intentions. Responsibility implies not only causal responsibility, but also that the actor owns his own intentions about his behaviors toward others.Responsibility, either as experienced by the actor or attributed by others, is a type of moral judgment; an exercise in moral reasoning. Following Gilligan (1987), I am persuaded that moral reasoning, or the discourse of ought-and-should is relational in nature and must be seen in the context of relationships. I think much of the early work on moral reasoning in offenders is flawed because it assumes that moral reasoning was a capacity like serum bilirubin: normally distributed out there in the population, and able to be measured by an objective observer, in a process independent of the findings. Unsurprisingly, these studies found either that offenders had immature moral reasoning capacities (which we might have guessed already), or they had normal moral reasoning capacity, which was disturbing and puzzling.What we want to understand is how people come to let themselves do horrible things to others. Cioccchetti argues that psychopaths can do these things because they lack the affective capacities needed to respond to others' distress. Ordinary people care about harm to others (including the physical self/body and sentient animals) and demand explanations for the deliberate infliction of suffering on others. It is not only the lack of participant attitudes in the psychopath that bother us; it is our own responses, expressive of our participant attitudes, that tell us something about what this person is, and what is wrong. In my view, this is what punishment is all about for us, the larger social group [End Page 185] forced to respond to the distressing and disturbing actions of others.As Ciocchetti suggests, it is the perceived guilt of the offender that justifies the punishment; it is also the experienced distress of those affected that drives the need for punishment. The distress is part of the relationship between the victim and the offender; the victim is often just as active as the offender.The issue becomes most clear in relation to capital punishment and its supporters, especially those who wish not only to view executions, but also to broadcast them. In considering this, there are two useful sources of information: first, studies of the reactions of those who witness executions, and second, studies of the impact of murder on those related to the murder victim, so-called secondary victims. In those states that have capital punishment in the United States, it is often the secondary victims who witness the execution. They often have testified to the appalling impact of the offender's crime on them; most states give them a right to be present at the execution, even if they do not exercise it. It is hard not to think that it is the enormity of the feelings caused by the offender's wrongdoing that the death sentence is designed to address; the death of the offender changes the relationship between victim and offender, as much as the death of the original victim changes the relationship with their relatives. One might then wonder about the impact of his or her execution on the relatives... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 15-18 [Access article in PDF] Through a Glass, Darkly:Commentary on Ward Gwen Adshead Keywords: psychopathy, moral reasoning. Now we see, as through a glass darkly.... (St Paul's first letter to the Corinthians, Chapter 13) JIM DID AN EVIL THING. He deliberately caused another person's suffering in a way that was humiliating, cruel, and persistent. He very nearly killed another man. He knew what (...) he was doing; he knew it was wrong, but somehow, that did not matter to him. After he was caught, he came to a forensic psychiatric facility where he was offered therapy. (What the purpose of therapy is could be the subject of a paper in its own right, although I will say a little more about this at the end of the paper). Several years on, Jim has had many thoughts about his behavior. First, he has no doubt that he was responsible insofar as he chose to do what he did, and he feels guilty on that count. Second, he is also aware that he had consciously carried out such acts many times in his mind before, but had not previously acted out his fantasy; and that therefore the process of crossing the line between fantasy and reality is a crucial one for him to think about further. This metaphor of a line that has to be crossed from one place to another suggests two worlds: one of internal reality and the other of external reality. Jim used the metaphor thus: "I came up to the line, but I drew back." He also said of this moment (when he nearly killed his first victim): "I said to myself... 'This is mad... I can't justify this.'... " I have emphasized these words of Jim's because I want to use his experience to explore some of the arguments raised in David Ward's most interesting paper. I found much to agree with, and some claims that sat less easily. I should say that the context of my response is my work as a psychotherapist with mentally disordered offenders in Broadmoor Hospital, and also a current research project with Jonathan Glover and Christine Brown on moral reasoning in antisocial men. Kant and Won't I have no doubt that most if not all of the men (and women) that I work with do operate according to universalizable principles. As the author suggests, however, these principles are incoherent and contain what Cleckley (1976) called a type of agnosia, or distorted vision. It seems to me that Kant's two forms of principle are really two different levels of intention or choice-making process. Kant's hypothetical level of intention is very much about making choices in the external world: I experience the world as cold, I want to be warm because I need to be warm, I will do what I need to do to make that need happen for me. It is not universalizable because [End Page 15] others may not feel the cold as I do. Notice that this level of intention may be very closely linked to the next level, which Kant calls categorical: I would like the world to be such that everyone who is needy will get their needs met, and I would like to be the sort of person who makes that happen. The categorical level of intention is Kant's take on the Golden Rule: that you should want everyone to be treated as you yourself would wish to be treated. It is an intentional process that is interpersonal, which implies a second order of thinking—thinking about one's thoughts and wishes, and thinking about the sort of person one would wish to be in relation to others.At this point, I think it may be helpful to bring in the other aspect of Kant's vision of moral intentions, which is the injunction to treat others as ends in themselves and not merely as means to ends. Thus every individual is a unique person or self, who claims respect as a person and not... (shrink)

Chapter 9 describes and evaluates the relatively recent mental health models of the impact of trauma, and discusses the ways that traumatic events affect people, the political and cultural effects of understanding these consequences as ‘disorder’, particularly as Post-traumatic Stress Disorder (PTSD), and concludes by looking at the relevance of the concept of PTSD to forensic populations.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 33-37 [Access article in PDF] "Impossible Things before Breakfast":A Commentary on Burman and Richmond Gwen Adshead "Why sometimes, I've believed as many as six impossible things before breakfast." --Lewis Carroll, Through the Looking GlassBoth Burman and Richmond discuss how a feminist critique or take on a body of theory helps to illuminate or confuse further theoretical development. Burman applies such a critique to (...) False Memory Syndrome (FMS); Richmond to psychoanalytic accounts of eating disorders. In this commentary, I want to discuss the application of a feminist critique to two vital concepts for psychiatry: the recording and measurement of data, and truthful accounts of experience. These concepts are of course related, and I want to explore their connections, not only with each other, but with specific areas of mental health practice, namely, mental health research, psychodynamic psychotherapy, and expert psychiatric testimony. The Recording Angel: Subjectivity and Objectivity, Measurement and Truth Most feminist critiques of measurement begin with an attack on the traditional theoretical distinction between objective and subjective worlds (for example, Fox Keller 1985). Classical accounts of Western scientific practice have assumed that it is possible to divide external physical experience in this way, and this assumption generates two further beliefs: first, that it is possible for an observer to, as it were, stand apart or outside the events observed, and second, that objective accounts of events are somehow real-er or true-er than subjective accounts. This account contains some very old ideas about natural experience: first, that a fixed reality exists that is external to those who have experienced an event, and second, that this reality is observable by others, that is, there is a space between the observer and the observed. This notion of objectivity has been thought to be crucial to valid measurement.In contrast, a feminist critique counterargues that every observer is influenced and influences what he is studying; that he is himself "positioned" in the subject of his interest, in Rom Harré's term. Further, feminist theory argues that because the objective-subjective split is artificial, subjective accounts of experience may be just as "true" as objective accounts. Overarching is the notion that all social behavior is socially constructed and affected by social context, including "science" in all its forms.Such doubts about the exact nature of science have been fueled by two sets of theory within [End Page 33] "science"--the claims of quantum theory in the 1920s and Thomas Kuhn's account of shifting scientific paradigms in the 1960s--and both of these theories have been important for feminism and feminist critique of scientific practice. Despite many odd features, quantum theory has produced research with considerable explanatory power (Hawking 1988, Barrow 1991, Smollin 1997), and some of its claims provide indirect support for the feminist position described above. For example, one claim of quantum theory is that, at the micro-level of events, what is being observed is influenced by the position of the observer. If true, then the notion of an easy divide between internal and external space, in which observer and observed are separately located, is undermined; rather, every position taken by the observer influences the observed in a dynamic relationship. There is no objectivity but rather a developing matrix of positions that are not externally fixed, but changing and uncertain. Similarly, in relation to social construction of theory, Kuhn's description of the changing nature of scientific paradigms also emphasizes the importance of social and community influences on scientific theories and how "true" accounts of events can change. Internal and External Worlds: Implications for Mental Health Research and Psychotherapy Practice Arguably, feminist claims about the social positioning of science are now unremarkable; no one involved in research (especially mental health research) could dispute that what is studied, what is funded, and what is published is hugely influenced by many social and political processes. Even if only to a limited extent, quantum theory and Kuhn do support the doubt thrown on classic notions of objectivity by feminist theory; if only by suggesting that reality... (shrink)

Philosophy says that life must be understood backwards. But . . . it must be lived forward. . , , It is more and more evident that life can never be really understood in Time. It was a pleasure to read Jason Thompson’s serious and thought-provoking piece, and I am grateful to the editors for giving me a chance to comment. The idea that the self is revealed in narrative is a popular one among different schools of psychotherapy, both in (...) terms of technique and theory; and my response addresses both these issues in turn. As a clinician, I have always liked people’s stories. As a junior psychiatrist, I used to love the moment when I first met someone and could say to them, ‘You were born; and then what .. (shrink)

I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn (...) about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical... (shrink)

We are more alike than we are different.In male prisons, the agency and antisocial mindset of violent offenders is taken seriously in the pursuit of rehabilitation. Male offenders are expected to own full agency for their cruelty and violence to others, and to explore it in supported rehabilitative group-work programs. Such programs have been shown to be highly effective for some offenders and relate to a process of engaging with a new pro-social identity and taking responsibility for leading a "good (...) life."Such programs hardly exist for violent women. Psychological services in female prisons rarely offer programs on anger management or opportunities to explore the wish to hurt or control; rather, they emphasize .. (shrink)

Feminist analyses address the way differences between the sexes are conceptualized and operationalized in society. In this paper, I discuss how violence by men and women is conceptualized as different in the psychological scientific discourses of forensic mental health. I suggest that these empirical discourses perpetuate assumptions of difference and discourage examination of similarities. Specifically, I will argue that neutralization techniques are frequently used that reduce women’s agency and responsibility for violence compared to their male counterparts, and compared to nonoffending (...) women. I discuss the implications for violence research and interventions for violence perpetrators. (shrink)

What drives someone to commit an act of terrible violence? Drawing from her thirty years' experience in working with people who have committed serious offenses, Dr. Gwen Adshead provides fresh and surprising insights into violence and the mind. Through a collaboration with coauthor Eileen Horne, Dr. Adshead brings her extraordinary career to life in a series of unflinching portraits. In eleven vivid narratives based on decades of providing therapy to people in prisons and secure hospitals, an internationally renowned forensic psychiatrist (...) and psychotherapist demonstrates the remarkable human capacity for radical empathy, change, and redemption. Based on 30 years of experience working in prisons and secure psychiatric hospitals with people convicted of serious violent offenses, internationally renowned forensic psychiatrist Dr. Gwen Adshead presents an account of mental illness and the nature of evil in this compelling series of stories. (shrink)

Szasz argues that the threat of harm to self or others cannot be understood as a symptom of mental illness, and that there is an irresolvable tension between the traditional medical ethical duty to heal, and any notion of a medical duty to protect the public.1 I think these are two distinct arguments which could each be the subject of extended analysis, and this commentary is of necessity limited.Professor Szasz has consistently raised concerns about the political abuse of psychiatry as (...) a way of controlling dissidence. Many of his arguments remain as cogent and unanswered as when they were first put 30 years ago. But as sympathetic as I am to some of his criticisms, it seems to me that many are too sweeping; especially the first claim that there is no such thing as mental illness, but only persons whose expressed intentions involve taking a stance which is contrary to certain social rules.I do not propose here to discuss the so called “hard” problem of consciousness—that is, exactly how brain states give rise to intentional psychological experience, or indeed, the extent to which “brain” and “mental” can be used synonymously. If we accept that mental states give rise to intentions, then different mental states will give rise to different intentions, and there is no reason not to think that there might be abnormal mental states that might give rise to abnormal intentions. The question then is what we mean by the word “abnormal”. Clearly it is possible for abnormal to be defined as “socially inappropriate”, which is Szasz’s concern. In that case, political and social dissidence is then turned into a symptom by the language of medicine, and thus becomes not a social matter, but an individual’s personal problem.But “abnormal” could be defined with reference …. (shrink)

Freely given informed consent to participation is the ethical cornerstone of research in health care. However, in mental health settings, there are many patients who lack the capacity to give such consent to participate in research. There is an abundance of guidance now available on how researchers might think about this issue and the Royal College of Psychiatrists has also recently reviewed its guidance to members about the ethics of research. In this piece, I will discuss some of the issues (...) that were raised during the revision process, and add some reflections of my own. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on“Psychopathy, Other-Regarding Moral Beliefs, and Responsibility”Gwen Adshead (bio)AbstractIn this commentary, I address two points raised by Fields: the origin of other-regarding beliefs, and the management of psychopaths, if they are not criminally responsible (as Fields suggests). I argue that the capacity to form affective bonds is necessary in order to hold other-regarding beliefs, and that a psychological developmental perspective may be helpful in understanding the moral understanding of (...) the psychopath. In response to Fields’s view that psychopaths should receive “treatment,” I suggest that most forensic psychiatrists do not agree.Keywordspersonality disorder, empathy, development, remorse, attachment theoryInsufficient attention has been paid to the problem posed by so-called “psychopaths.” Lloyd Fields’s paper is therefore welcome. Here I shall focus on two issues: the nature and acquisition of other-regarding beliefs, and the implications for managing those who do not have them.Fields argues that there is a subgroup of psychopaths, unable to form “other-regarding beliefs”; that such beliefs provide a motivation for acting in a particular way, and result in a “[disposition] to experience certain emotions and to have certain attitudes.”But it is arguable that the disposition to experience certain emotions and have certain attitudes towards others could be critical to acquiring the capacity to have other-regarding beliefs. If one asks what stops people from hurting others, a common answer is that it makes people feel bad. To quote Mencius (Legge, 1960): “All men have a mind which cannot bear to see the suffering of others.”The question then is, how does anyone acquire a notion of “the other,” such that failing to endorse other-regarding principles/beliefs has an adverse effect on the subject?Mencius’ “mind” implied “reciprocity,” and involved four components:i. The recognition of another’s distressii. Being moved by that distress (empathy)iii. Wishing to reduce that distress (sympathy)iv. Altruism (the sense of obligation to reduce distress, and guilt if one fails).By these criteria, (iv) resembles Fields’s “other-regarding” belief, in that the sense of obligation provides a reason for acting. I would argue that (iv) is a virtue, which requires (i), (ii) and (iii) as capacities—not necessarily separate, but different aspects of a broader “affective” capacity. It is this affective capacity which is arguably lacking in the psychopath.Some of these capacities have already been discussed in the literature of psychopathy. It is the [End Page 279] failure to recognize another’s distress which Cleckley describes in many of his cases (Cleckley 1964), and which he describes as a type of “agnosia.” This term implies some neuropathological deficit, and there is some evidence for such deficits in psychopaths, mainly in the autonomic nervous system. Blair (1995) has also suggested that psychopaths lack a (postulated) violence inhibitory mechanism (VIM).It could be argued, however, that such neuropathological hypotheses lead to circular arguments about psychopathy, as described by Barbara Wootton 1(Wootton 1959). A more fruitful account is offered by theories (such as attachment theory) which offer a developmental account which includes both psychological and neuropathological perspectives. Described and developed by Bowlby (1969), attachment theory draws on experimental work with non-human primates and emphasises the importance of relationships with significant others in infancy for the development of later social relationships (Harlow 1975; Ruppenthal et al 1976). Such attachment relationships are also important for the development of cortical neural networks, and the modulation of stress, which can itself be neurotoxic (Sapolsky 1994).How could attachment theory be relevant to acquiring an affective capacity? The earliest work on attachment behaviors showed that monkeys failing to make early attachments behaved recklessly with other monkeys, and could not make relationships (for example, to mate). Of particular relevance was the finding that such monkeys launched suicidal attacks on monkeys higher in the hierarchy; not dissimilar to those “self-defeating” behaviors which Cleckley described in human psychopaths.So much for possibly psychopathic monkeys; do humans with failed attachments lack affective capacity? There is evidence that substantial proportions of “psychopaths” have histories of failed attachments in childhood. The more severe the failure, the more severe the disturbance in adulthood, which might explain why there... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice and ViciousnessGwen Adshead (bio)Keywordspsychiatric diagnosis, antisocial behaviorI am Grateful to Professor Sadler for such a clear and helpful account of how human misconduct (or vice) has been confounded diagnostically with human disease (as defined by the Diagnostic and Statistical Manual of Mental Disorders [DSM] classificatory system); and even more grateful for the chance to offer comment. Professor Sadler’s paper raises questions about the DSM enterprise as a whole; (...) and this is a field in which I have no particular experience to offer for additional discussion. But his other main point is that psychiatrists are constantly invited to distinguish between vice and disease, and he gives three examples, one of which is a clinical case from my own research. I entirely agree with him that this is a good example, and in this commentary, I will explain why.The argument is about how to distinguish between human behaviors that reflect chosen deviance from prosocial norms and behaviors that reflect a diseased state of mind. Arguments are both legal and political: Aristotle, in the Nichomachean Ethics sets out conditions in which a man should not be blamed for his behaviors, and to some extent these conditions still hold good in the criminal court; ignorance of the meaning of one’s actions, or being forced to act under duress, are good legal defenses. Politically, as Professor Sadler makes clear, the arguments were set out first by Foucault and then Szasz; it is possible for the state to use medical discourse to turn what might be a legitimate social grievance into individual pathology—the ultimate ad hominem argument.These arguments have not gone away, despite the best efforts of a materialist wing of neuropsychiatry, aided and abetted by pharmaceutical companies, who have a great interest in reductionist arguments in the biosciences. This is particularly so in relation to antisocial behaviors, especially crime. I want to focus on one particular type of antisocial behaviors, namely, the wish to hurt another person. I focus on this because it is my clinical bread and butter: My work as a forensic psychiatrist and psychotherapist requires me to try and understand how and why people want to hurt others. But I think it also makes sense to focus on this because it is the most problematic wish socially and demands understanding. All three of Professor Sadler’s examples involve hurt and harm to others, and it is noteworthy that neuroreductionist or medicalized explanations are rarely sought for theft or tax evasion. This must be in part because socially we think it is normal to try and profit yourself, even illegally, if you can get away with it. (I actually think that such behavior is not all that normal, but that is an argument for another day).Let us take the clinical example from my own work, cited by Professor Sadler. It is an example of what is called in the DSM “Factitious Disorder by Proxy” (FDP), although it also has an unhelpful eponym of “Munchausen’s Syndrome by Proxy.” As a practicing forensic psychiatrist, it is one of the best examples I know of what has been crudely dichotomized as a “mad or bad?” debate. A [End Page 23] mother quite deliberately makes her child ill, and then presents the child to medical services as in need of hospital treatment. In the case I described with Dr. Bluglass, the mother smothered her baby girl and then presented her as having “breathing difficulties” (which was, of course, quite true in one sense). There are two examples of vice here: deliberately hurting your child and lying to others about it; the lies also have the indirect result of potentially causing more harm to the baby. Harming your child, and then lying about it, in a not-for-profit way, are criteria for FDP.Quite how these actions ever made it into the DSM is puzzling, when they are quite straightforwardly antisocial. If a man in the street were to smother another man to the point of asphyxia, and then lie about it, we might well ask many questions about why he had done it, but we would not say that no offence had occurred. We... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What’s His Story?Gwen Adshead (bio)Keywordsnarrative, violence, identityIn this commentary, I discuss three issues raised by Cartwright: whether and to what extent explanations from the past can adequately explain or excuse present actions, the nature of moral identity, and the notion of the moral community.I have often thought that psychiatrists and psychotherapists working with offenders have to be like writers of detective fiction. To make the story convincing, the writer (...) of detective fiction has to convey to the reader an understanding of the killer's motives. The successful writer enables the reader to appreciate the killer's reasons for killing; and these reasons offer to readers a tantalizing glimpse of what it might actually be like to be a violent and dangerous person; or more particularly, one who acts on their cruel and violent thoughts.Psychiatrists want to understand the reasons for their patient's violence, for several reasons (which probably include the voyeuristic pleasure that all humans seem to have at other people's disasters). However, the main reason is to do with prevention of future harm; if we understand the reasons that this happened, then we can take steps to make sure that it does not happen again. This view has been called the just world theory (Janoff Bulman 1989), which implies a world of predictable causes and reasons, where disasters occur because of an identifiable fault or omission that can be rectified with good result. The payoff of this view is that it gives the believer a sense of control, which after a disaster is important for maintaining confidence and self-esteem.The problem with this theory is that it presupposes that the world of human actions is essentially rational, and that people do things for reasons that make sense to them. However, much human cruelty has an irrational and unreasonable aspect to it; one that literally makes no sense. Cartwright's paper begins with a narrative about real people doing really dreadful things for no reasons that would ever satisfy the average detective story reader. Forensic mental health work is full of histories that are actually much stranger than any detective fiction.But it seems that humans are not happy with stories that do not make sense, even if senselessness is part of the natural world around them. As Cartwright indicates (see p. 150), when we hear about people like Robert Harris, we immediately move the field of inquiry from "Why did he do that?" to "Why is he like that?" With the rise of developmental psychology over the last 150 years, it has become natural to look at people's histories to see if this explains the person's present identity. In this sense, therefore, we seem to be natural Aristotelians, assuming that a man's character is revealed by his current actions: we also seem to be assuming that a man's character is an expression of past actions and events. [End Page 157]His-Story: Explaining the PresentIs this in fact the case? To what extent is it true that our identities are shaped by our past experiences? Even if this were the case, shaping is not the same as determining. There has always been a risk that developmental psychology will take up a similar position to genetics, with regard to explaining behavior; namely, that there are those who will try to argue that the presence of this, that, or the other gene, or this, that, or the other experience, both determines and "explains" the behavior. The moral point here is that when it comes to violent and antisocial behaviors, a person's past history is said to simultaneously explain the behavior, determine the behavior, and excuse it, by implying that the actor had no choice about what he did, given his past. This has been taken to an extreme in the US criminal courts, with what Dershowitz (1994) has called "the abuse excuse" (used most notably in the trial of the Menendez brothers, who killed their parents and claimed at the trial that their parents had abused them).Trials are about evidence, and it is worth considering the evidence about the effect of early childhood adversity... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tyranny of the BureaucratsSimon Wilson (bio) and Gwen Adshead (bio)Keywordsviolence, mental health, bureaucracyWe are grateful for the opportunity to respond to the two kind and thoughtful commentaries on our paper. Sadler suggests irrationality may be the key to distinguishing psychiatric from nonpsychiatric violence. We are not so sure that this is necessarily as helpful as it might at first seem. Who gets to decide what is rational? Much (...) “normal” violence, committed in the heat of the moment, impulsively, and drunkenly, may not appear that rational, even to the perpetrator, in the cold light of day. We are not sure one would wish to bring this sort of violence within the province of psychiatric explanations. Likewise, a point we made in our paper: Even delusionally driven violence often has its own internal coherence and rationality within an irrational framework.We found much to agree with in McCallum’s commentary, and perhaps his alternative approach is more helpful. He proposes a more sociological model of understanding what is going on in these complex cases, one that starts with societal dividing practices. Our present times have been described as the tyranny of the bureaucrats. Professional approaches are devalued. Diagnosis is only relevant in terms of its bureaucratic utility in moving people from one category to another. Since the writing of our paper, the criminal law has changed further in England and Wales. The Criminal Justice Act 2003 brought with it new sentences of indeterminate detention for public protection for those offenders categorized as “dangerous.” The presence or absence of psychiatric disorder being largely irrelevant for these purposes. This would seem to fit nicely with McCallum’s analysis, and in principle rather takes the wind out of our sails when we argued about the discrimination against psychiatric violence—now a diagnosis is not necessary for the state to intervene in a probabilistic fashion to prevent future violence. Deciding between what sort of violence counts as psychiatric and what does not, does not have quite the same drastic differential effect on the individual as perhaps it did. Its importance is now, as predicted by McCallum’s model, more to do with bureaucracy: Which government department will be paying for the individual’s preventive detention (Department of Health or Ministry of Justice)? [End Page 75]Related ArticlesFeature Article: When Violence Becomes a Psychiatric SymptomCommentary: The Contingent Object of PsychiatryCommentary: Reasons CountResponse: The Tyranny of the BureaucratsSimon Wilson Simon Wilson is a Consultant Forensic Psychiatrist at the Maudsley Hospital and an Honorary Senior Lecturer at the Institute of Psychiatry, London, UK. He qualified at Leeds University and trained in psychiatry at the Maudsley Hospital. He was previously Consultant Forensic Psychiatrist at HM Prison, Brixton, UK. He has particular interests in prisons, philosophical, and ethico-legal issues in psychiatry. He can be contacted via e-mail at:[email protected] Adshead Gwen Adshead is a Forensic Psychiatrist and Psychotherapist. She works as a psychotherapist in a high-security hospital. She is a group analyst and researcher in attachment theory as it relates to offenders. She has a Master’s degree in Medical Law and Ethics, and is a founder member of the Philosophy Special Interest Group of the Royal College of Psychiatrists. She can be contacted via e-mail at:[email protected] © 2009 The Johns Hopkins University Press... (shrink)

Psychiatrists are increasingly expected to be involved in violence assessment, prediction, and prevention. For some psychiatrists this sits uncomfortably with their conception of themselves as doctors. Is violence (ever) a medical/psychiatric symptom? If so, what is the role of medicine/psychiatry in preventing violence? What are the consequences of an interventionist stance? We attempt to explore some of these questions in this paper.