Dangerous People With Severe Personality Disorders

To the Editor: We read with interest the Law and Psychiatry column in the April issue, "Dangerous Severe Personality Disorders: England's Experiment in Using Psychiatry for Public Protection" (1), which describes a government proposal in the United Kingdom (2) to expand the use of psychiatric facilities to treat psychopathy and similar conditions that are widely viewed as untreatable. One of the problems we face as psychiatrists is that from the societal viewpoint, we are damned if we do and damned if we don't. We constantly strive to find a balance between the need to treat symptomatic persons who have no insight into their mental illness and the need not to trample on their civil liberties. Finding that common ground has not been easy.

Psychiatrists share the government's concern about public safety. Public safety is one of the main thrusts of the proposal, which is part of the effort to reform the U.K. Mental Health Act. In light of Dr. Appelbaum's critique, we highlight some of the elements of the Mental Health Act that ensure that patients' civil liberties are not usurped.

First, in England and Wales, involuntary commitment of an individual can be valid only if an approved social worker and two independent attending-level psychiatrists agree. Second, the psychiatrists and the social worker must be certified by the Secretary of State in the diagnosis and treatment of mental disorder after they attend an extensive course described in the Mental Health Act. This certification is renewable every five years after a mandatory refresher course. The course material presents various situations in which involuntary committal may be necessary and emphasizes that an individual's liberties must not be usurped.

Third, even though the framework addressing "dangerous people with severe personality disorders" permits detention for an indeterminate time, such detention is reviewable by the Mental Health Review Tribunal. Fourth, contrary to Dr. Appelbaum's assertion, a sizable percentage of patients appeal to the tribunal. In 1997, there were 24,200 involuntary commitments and 14,942 appeals to the tribunal (3). Fifth, patients' families also have the legal right to question any detention that they perceive as unfair. Furthermore, after a certain period, the hospital where the patient is committed is legally bound to appeal to the tribunal on behalf of the patient, whether the patient desires it or not.

Finally, in some circumstances, after a patient's further appeal, the High Court can overturn the results of the tribunal by a procedure called judicial review. During all these appeals, private lawyers (rather than public defenders), who are funded by the legal aid board, give patients expert legal advice (4).