Involuntary psychiatric care in Sweden: current controversies

Young female patients with self-harm have been treated at forensic psychiatric clinics in Sweden, even if they have never been charged with crimes or convicted. Some have been as young as 16 years of age, placed in the same wards as notorious violent or sexual offenders, prevented from locking their door during the night, and at least one rape in a “high-security ward” has been reported.

Several reports, including an autographical book (End-station Forensic Psychiatry by Sofia Åkerman and Thérèse Eriksson) and an investigative TV program aired yesterday, highlight how illegal forms of restraint have been used routinely at certain clinics, including locked hockey helmets, leather gloves and forearm plasters. A study by Herman Holm and co-workers (Journal of the Swedish Medical Society, 2011) found that the largest group of patients treated under the Involuntary Care Act was indeed young women with personality disorders, and that they had been subjected to physical restraints more often than other groups of patients.

Interstingly, this has been known to the authorities in charge of over-seeing the health care system for many years, and numerous complaints have been filed to the police. Official criticism has been raised, but no doctor or hospital director has been prosecuted, and the public clinics responsible have been more or less let alone by the authorities. Instead, the treatment programmes are slowly being stopped based on “media pressure”.

This shows that psychiatric practice may run a course that is not consistent with the intentions of the legislator, even in flagrant conflict with the law. 

Unfortunately, the last decade has seen the development of a much more repressive psychiatry in Sweden. New clinics are built outside cities surrounded by walls, electronic supervision and involuntary out-patient treatment have become common, and a governmental report has proposed changes that would reduce patient autonomy even further: involuntary care would be initiated among out-patients who have never needed in-patient treatment, a mere professional opinion that the patient needs involuntary care to avoid a relapse would suffice for involuntary treatment and mentally ill persons would be subjected to special measures for “societal protection” after having served penal sanctions.

Fortunately, the only proposal that has come from the government to this day rejected the idea of a “committee for exemptions” that would be able to grant authorization for otherwise illegal measures of restraint retrospectively. According to the proposal, users would not be granted even a single seat in the committee.  

Uppdrag granskning: Om tvångsvård av patienter med självskadebeteenden i rättspsykiatrin 24 september 2014 (Swedish)

I gårdagens Uppdrag Granskning visades hur unga kvinnor med självskadebeteenden vårdas inom rättspsykiatrin. Bland annat hade de fått underarmarna gipsade under lång tid, lagts i bälte stort antal gånger och placerats tillsammans med dömda personer. Liknande berättelser finns i boken Slutstation Rättspsyk av Sofia Åkerman och Thérèse Eriksson som kom 2012. Denna bok har inte fått den uppmärksamhet den förtjänar. Den är välskriven, nyanserad och lärorik. Framförallt pekar den på systemfel i svensk psykiatri och tillsynsmyndigheterna.

Lagen om Psykiatrisk Tvångsvård (LPT) och Lagen om Rättspsykiatrisk Vård (LRV) ger möjlighet till vård oavsett patientens samtycke om det föreligger en allvarlig psykisk störning och vissa andra förutsättningar är uppfyllda. Vården prövas av Förvaltningsrätten. Lagen är tydlig med att frivillighet alltid skall gå före tvång och att frågor om behandlingen skall avgöras i samråd med patienten "när det kan ske". Samtidigt sägs det att "Frågor om behandlingen avgörs ytterst av chefsöverläkaren".

Förutom behandlingen finns några reglerade tvångsåtgärder, som bland annat är avskiljning, fastspänning och inskräkningar i rätten att kommunicera. Dessa åtgärder kan användas för att undvika skador under begränsad tid. I öppen tvångsvård ser det olika ut beroende på vilket lagrum som reglerar vården men generellt är möjligheterna till tvång starkt begränsade om patienten inte återintas för sluten vård. Detta har också förtydligats av Regeringsrätten.

Detta innebär att en patient som vårdas enligt tvångslagarna i hög utsträckning är utlämnad till chefsöverläkaren när det gäller behandlingen. Chefsöverläkaren har sista ordet när det gäller medicinering, placering och föreskrifter om vården. Vissa nödvändiga somatiska vårdåtgärder kan också genomföras med stöd av tvångslagarna, som alltså ger utrymme för elbehandling, provtagning, operationer och andra medicinska behandlingar mot patientens vilja, även om detta alltid är (eller skall vara) en sista utväg för att undvika död eller allvarliga skador. Om gipsning av såriga underarmar är nödvändigt för sårläkningen kan jag inte se att det skulle vara olagligt för chefsöverläkaren att besluta om sådan behandling.

Och - viktigt att säga - det finns lägen när mycket få skulle vilja vara utan möjligheten att bli behandlad mot sin vilja. En GHB påverkad ungdom som behöver magpumpas, en förvirrad person med diabetes och livshotande blodsockervärden, en person som tappat verklighetskontakten och förnekar att han eller hon har en cancertumör som går att operera bort men riskerar att spridas om man dröjer för länge. En förvirrad, nedkyld person i en snödriva utanför akutmottagningen. Och förstås allvarliga psykoser som kräver psykiatrisk behandling. Det är lätt att tänka sig situationer där någon form av tvång är nödvändigt och något man skulle vara tacksam för efteråt. Just därför är det så viktigt att sådan vård bedrivs på ett etiskt, medicinskt och juridiskt föredömligt sätt.

Och det är svårt att tro att det är så det ser ut i psykiatrin och rättspsykiatrin idag. I själva verket är missförhållanden kända sedan årtionden bara i den senaste "vågen" av uppmärksamhet, med exempel från "fallet Elisabeth" till Slutstation Rättspsyk och gårdagens Uppdrag Granskning. Herman Holm och medarbetare publicerade 2011 resultat som är bland de viktigaste i svensk klinisk psykiatrisk forskning på länge: majoriteten av tvångsvården och tvångsåtgärderna används inte mot akut farliga, fysiskt svårbemästrade patienter med akuta psykoser i väntan på att medicinering och annan behandling skall ha effekt (som lagstiftaren avsett) utan mot unga kvinnor med personlighetsstörningsdiagnoser.

Allvarlig psykisk störning är ett medicinskt-juridiskt begrepp som främst motsvarar allvarliga psykostillstånd. Personlighetsstörningar kan bedömas som allvarlig psykisk störning om de är av särskilt svår grad med frekventa psykosgenombrott eller tvångsmässighet. Vidare kan några andra svårt tvångsmässiga tillstånd vara allvarlig psykisk störning i lagens mening. Men utifrån förarbetena till lagen och Socialstyrelsens författningar är det svårt att förstå hur personlighetsstörningar kan bli den största diagnosgruppen. Och ännu svårare är det förstå hur just unga kvinnor kan vara den grupp där fastspänning oftast är motiverad utifrån att alla andra möjligheter att få kontroll över en farlig situation är uttömda. Det förefaller uppenbart att psykiatrin utvecklat en egen praxis för tvångsvård som inte står i överensstämmelse med lagstiftarens intentioner.

Som om detta inte var nog beskriver "Slutstation Rättspsyk" en lång rad, direkt olagliga tvångsåtgärder. Hockeyhjälmar och lädervantar har införts lokalt, bältesläggning har använts som bestraffning eller en del i behandlingen, vården har pågått efter att domstolsbeslut löpt ut. Naturligtvis är gipsning olaglig på samma sätt om den använts som en "skyddsåtgärd" eller del i tvångsvården utöver vad som kan motiveras medicinskt för sårläkningen. Dessutom vet vi att tvång och fysiska begränsningar ökar risken för självskadebeteenden och leder till en destruktiv upptrappning av skadorna. Bo Hejlskov Elvén beskrev lovande behandlingsalternativ i Uppdrag Granskning och självskadebeteenden är ett område där kunskap och nya behandlingsmodeller behöver utvecklas.

Två slutsatser av detta måste nu lyftas i samhällsdiskussionen.

• Användandet av olagliga tvångsmedel är ett brott, som varit känt hos Socialstyrelsen under lång tid och anmälts till Polis och Åklagare vid upprepade tillfällen. Nu har tillsynsansvaret lagts över på den nya myndigheten IVO. De professionella yrkesorganisationerna Svenska Psykiatriska Föreningen och Svenska Rättspsykiatriska Föreningen har också varit medvetna om situationen. Ändå har dessa myndigheter och organisationer stått handfallna inför vad som pågått. I Slutstation Rättspsyk beskrivs hur Socialstyrelsen år efter år riktade kritik mot de olagliga tvångsmetoderna utan att få klinikens läkare att ändra sig, och då bara lät tiden gå. Denna kapitulation inför övergrepp som begås i sjukvården, och yrkesorganisationernas tystlåtenhet, är på många sätt mer anmärkningsvärd än enstaka desperata åtgärder på "vårdgolvet". Den enda myndighet som verkligen gjorde något var den (nu nedlagda) Hälso- och Sjukvårdens AnsvarsNämnd (HSAN), som varnade en hel grupp läkare för lagstridiga tvångsåtgärder i ett av sina sista beslut. Ytterligare ärenden lär ha lämnats utan åtgärd efter att nämnden lades ner. Hur skall efterlevnad av lagen och rättssäkerhet försäkras i framtidens psykiatri?    
• LPT och LRV infördes 1991 som ett försök att minska användningen av tvång i psykiatrin och få en bättre juridisk kontroll. Fram till slutet av 1990-talet var det en uttalad politisk ambition att stärka patienträttigheterna och minska tvångsinslagen. Sedan hände något. Flera statliga utredningar och lagändringar har gått i rakt motsatt riktning. Tvång i öppenvård har införts. Kliniker byggs utanför städerna med elektronisk övervakning, "perimeterskydd" (ibland 4 meter höga murar och järnstänger över "rastgårdar") och inpasseringskontroll. Patienternas möjligheter till kommunikation begränsas. Varje patients behov av säkerhet skall bedömas men inget hindrar att en patient vårdas på en högre säkerhetsnivå än den som är nödvändig. Det har byggts mängder med högsäkerhetsavdelningar utan att någon nationell behovsanalys eller samordning företagits. Mobila bälten är på förslag. Och det kunde varit mycket värre. Psykiatrilagsutredningen föreslog att tvångsvård skulle kunna inledas i öppen vård, att läkarens bedömning att utebliven vård skulle kunna leda till försämring skulle räcka för tvångsvård, att psykiskt sjuka skulle utsättas för särskilda samhällsskyddsåtgärder efter avtjänade brottspåföljder (fast de snarast är mindre återfallsbenägna än andra dömda), att tvångsåtgärder skulle kunna vidtas i patienternas hem eller i öppenvården, och, kanske mest anmärkningsvärt, att en dispensnämnd skulle inrättas för att sanktionera olagliga tvångsåtgärder i efterhand. Av detta har hittills inte blivit något lagförslag. Men hur vänder vi utvecklingen mot en alltmer repressiv psykiatri?     

Professional ethics in forensic psychiatry

Even if I work at the Centre for Ethics, Law and Mental Health (CELAM) at the University of Gothenburg, I am no specialist in ethics and have never studied practical philosophy. This post is thus not written by an expert in ethics, and I doubt that my colleagues who hold such qualifications would agree with much of it. Nevertheless, I want to argue for some positions I have arrived at through my work as a clinician and researcher. Forensic psychiatry is a medical speciality operating in the interface towards law. It is sometimes argued that we have a “dual task” of promoting our patients’ health and protecting society from violent (re-)offending. I reject this idea, and will outline the reasons for this here.

My position is that, as health professionals, our sole duty is to further the best interest of our patient. By health professionals, I refer to board licensed MDs, psychologists, psychotherapists, social workers, nurses and other professions employed in the health care system. Being a health professional requires that other people put their trust in you in very special ways. Therefore, we have ethical rules that must always be adhered to. To do our work, we can literally ask a fellow human to undress or to reveal his/her innermost secrets. Sooner or later, most of us will need a health professional. In the vulnerable position of the care seeker, and to get good treatment, we must be able to trust that the professional is dedicated to promoting our health and not serving two masters. 

Before going further into the arguments for my position, let me state that it is never in the patient’s best interest to commit a violent crime, having drugs prescribed without medical indication, false certificates issued or the similar.

Psychiatrists may give court expertise on evaluations and treatment, if the patient waives professional secrecy. In cases of diminished or incapacitated accountability, special legislation is at hand to safeguard the patient’s best interest. But the model in which a psychiatrist may “change hats” and give evidence against someone, working for the state or the prosecution, putting aside normal medical ethics, damages medicine at large. 

The reason the court asks for a psychiatric or psychological opinion is that the expert has specialist training (based in the confidence of patients and research subjects) and clinical knowledge (that demands access to information that the patient has provided under the impression of confidentiality, either directly to the expert or to other experts, who have entered it into files). Being a qualified health professional also brings credibility and power imbalance, making it difficult for the person described to question the expert’s opinion.

It does not suffice to merely state that “this opinion is made as expert for XXX” as established titles, such as MD, will create certain expectations in those receiving the evaluation. In contrast, it could be possible for a psychologist to work as a behavioual analyst and give expertise in that role. Such cases have to be handled with great caution, however, in order not to confuse previous or future clients.  

But with these requirements, how could medical doctors work in forensic medicine or with societal response to contagious diseases? Frankly, I do not know how ethical frame-works, especially for the latter, have been developed, but I do not find clear analogies to forensic psychiatry. Psychiatry has a rather weak inter-rater reliability, and courts tend to believe us more easily than our colleagues do, who often disagree with our opinions. And without trust from patients, we are completely lost. So I do not find the responsibilities and benefits of assuming the role of “(s)he who knows” in the courtroom worth the risks for our profession. 

Not doing harm is our first duty. How is that possible when giving expert opinions in situations where we have no control over how the expertise is used, disseminated or understood? Instead, I think that we should use our scarce resources to develop good health services to incarcerated or otherwise sentenced persons, evidence-based treatments for aggressive behaviours and public mental health education.

Risk assessments in forensic psychiatry

Risk assessments form a core task for forensic psychiatrists. This is not the place to review the scientific literature on the various methods and instruments used for this purpose, an excellent meta-analysis is provided by Seena Fazel and colleagues here. Instead, I will raise some simple points that sometimes disappear in the scientific litterature and expert evaluations.

Generally, risk assessments in forensic psychiatry are based on a rating scale or a check-list, in which items reflecting risk (and sometimes also protective) factors are systematically weighted and added. The results of one or several such scales are subsequently evaluted by a clinician, who can override or modify the results from the instruments in a final evaluation documented for the court, hospital record or similar. In Sweden, the global risk is assessed as Low, Medium or High (for unspecified crimes during an unspecified time-frame).

Scientific support for the methods are derived from longitudinal studies (prospective or retrospective), comparing assessments to actual outcomes. Assessments of risk for relapse in violence or criminality typically have Areas Under Receiver Operating Characteristics (ROC) Curves (AUC) between 0.70 and 0.80, considered modest or moderate predictive validity. To AUCs, other statistics, such as Diagnostic Odds Ratios (DOR) and Number Needed to Detain (NND), are added for further detail. The overall consensus seems to be that a. these instruments perform better than chance alone and b. that there is no clear evidence that one method is better than the other.

Some aspects are clearly missing in this picture. First, the strongest predictor of future human behaviour is the previous behaviour of the individual. Who among us will be slim and fit a month from New Year's Eve? Probably those who were last year. This is the backbone of every psychiatric risk assessment instrument. The relevant question for science would be "does this instrument/method add predictive value to that derived from the individual's history of previous behaviours?". Why keep repeating that methods are better than random when this can be achieved by common sense alone?

In the whole Swedish population, the risk of being convicted for a violent crime is <4%. After one conviction, the risk for another conviction is still less than 50%, but after two convictions, a majority will go on to reoffend (59%), climbing to 68% after three convictions, >80% after seven and >90% after 11 (Örjan Falk and coworkers, here). These figures may solve the old ethical dilemma whether preventive efforts can be directed at individuals who have not yet offended. It may suffice to do something about those who have.

Second, the time-frame is neglected. Often, the studied time-frame is determined by convenience: researchers take what they can get from data-sets. But clearly, the risk for reoffending varies according to situational factors, such as relapse in substance abuse or unstable social relations. And preventive efforts are best motivated when relapse comes in a reasonable brief time-frame, in some way corresponding to the “normal” prison sentence the offender would have received. It hardly seems justified to allocate large ressources to prevent a threat five years down in time, while 20 years of efforts are clearly appropriate to prevent a murder.

Third, the type of outcome should be specified. A high risk for threats is not easily compared to a medium or low risk for murder.  

Therefore, my advice is:

• for legislators and courts: base risk management decisions on what is known about previous violent behaviours.
• for health care staff: assess risk in a here-and-now perspective based on both actuarial and clinical factors with your patient's best interest as goal (which includes not to commit violent crimes!), do your utmost to help and prevent misfortunes of every kind, but desist from speculating about future behaviour.
• for scientists in the field: develop evidence-based treatments that prevent violence and study risk in fine-grained, clinically meaningful models.

Mt St Helens 1980 eruption

Some books, films or journal views make an unforgettable impression, while others, as interesting and well-presented, just fade. I will never forget the January 1981 National Geographic cover story on the eruption of Mt St Helens in Washington State. One of the Cascade volcanoes, Mt St Helens had been known to erupt in the 19th century, but had been dormant for more than hundred years. It was a very beautiful, Fuji-shaped mountain, a stratovolcanoe like Mt Teide on Tenerife, if smaller. It overlooked Spirit Lake where sport resorts and fishing lodges had among the most wonderful sites and views in America. In March 1980, a series of small earthquakes had been registered and, as there had been no volcanic eruption in the continuous US since 1915, scientists immediately flocked  to study what was going on, monitor activity and try out new predictive tools. 

The eruption started on March 27 but was considerably smaller than the scientists had thought it would be. Activity continued, and seismic activity was continuous, while chemical samples (taken from the sides of the mountain but also in the crater (!) by daredevil scientists) didn't show signs of imminent danger. In May, the sesimic activity in the mountain seemed to settle again and public pressure to lift warnings and security measures started to mount. So did, however, the magma pressure in the mountain. It was even visible for the naked eye, as a buldge had formed on the northern slope. Laser measurements assessed the growth to one meter and a half per day (!). In this situation, volcanologists could persuade the governor to keep access to the “red zone” closed, the area around the mountain thought to be directly hit if the mountain had a Plinian eruption, explosive like that described by Pliny the younger at Mt Vesuvius in 79, which destroyed Herculaneum and Pompeii. However, some residents and lumber companies refused to evacuate, tourists continued to flock around the mountain, trying to evade road blocks, and the scientists kept watch from several observation spots.  

At St Helens, volcanologists worked with three types of predictors when assessing the risk for an eruption: seismology (earthquakes), chemistry (gas and water emissions) and geology (deformation, previous eruptive history). By combining these factors in "event tree" algorithms, the accuracy of newer predictions is estimated to have moderate to good predictive ability for short term predictions (Areas under Receiver Operating Characteristics Curves of 0.78-0.81, Junek and co-workers, 2012, Algorithms, which is an estimate of the validity of the method rather than the security of a single prediction). Just as in psychiatry, a “clinical override” is also allowed for, so a senior volcanologist can have an experience-based opinion that takes precedence before the results of the algorithm. And Mt St Helens proved to be a testing ground for many new tools used routinely today to predict volcanic activity.  

On Saturday, May 17, the mountain was so calm that residents in the red zone were allowed a brief entry from 10 AM to 4 PM to collect property. A similar opening was planned for the following Sunday.  The weather was clear and sunny, with a very good visibility. Fortunately, Sunday meant the loggers had the day off. At 8 32 AM Sunday morning, the whole northern flank of Mt St Helens suddenly collapsed and gave way to a Plinian eruption, which also contained what is referred to as a “lateral blast”, a sort of eruptive column going side-ways instead of upwards. The consequences were terrible. Fifty-seven people died, among them several scientists and journalists, the most well-known being David Johnston, who had predicted just a lateral blast based on the bulge but nevertheless remained at an observation post overlooking the north face of the mountain from about 10 km. No film of the eruption survived, but several series of still shots taken in rapid succession made a very detailed reconstruction possible (below). A detailed description is given in the Wikipedia entry on the eruption. Several other interesting films describing the sequence of eruptions and its aftermath are available on YouTube. The events were also used in several movies, among them St Helens and Dante's Peak.  

Due to the lateral blast, the zone of destruction was much larger than the predicted red zone, and many victims died in areas considered medium or even low danger. Rapidly after the blast, mud flows created by rapidly melting snow on the mountain hit further victims down the river beds. After his visit, US president Jimmy Carter said that, in comparison to the devastation wrought on the countryside to the north of the volcano, the “moon looked like a golf course”.  Fortunately, as the area around Mt St Helens was sparsely populated and, at least partially, evacuated, the death toll was two-figure and not much worse.  When volcanoes like the neighboring Mt Rainier, which overlooks Seattle and many smaller cities in its river valleys, come to live, the responsibility put on the scientists will be unfathomable.

A last word of hope. At first, scientists thought that the blast zone would remain sterile and life-less for a very long time, up to a century. For the 30th anniversary of the eruption, a nature TV documentary was produced. It really shows how amazingly fast life is to reclaim lost areas and fill them with wonders anew.


On Friday, the next blog entry will deal with the science of predicting future dangers in forensic psychiatry as compared to volcanology. I also plan to read some more pappers on predictions in volcanology, as their use of event trees and short-span predictions are very interesting, and to present it in some blog post. And if you followed the path to the 2014 Bardarbunga eruption, which is currently ongoing, seismic recordings posted on the internet made it possible to see how the magma rose in the volcano day by day, and where it would eventually erupt. But also in Iceland, major risk assessments are currently performed, and can be followed on the website linked to bardarbunga (The Icelandic Met Office)

Persistent aggressive antisocial behaviour: a promising phenotype

The main ambition for this blog is to provide a decent, science-related and thought-provoking text on forensic psychiatry once a week ("Forensic Friday"). Let's start by the quite basic question: what is the object of forensic psychiatry? What are we working with? During my first decade or so in this peculiar speciality, I often wondered where the focus of my research and clinical work lay. In psychoses, disorders of empathy, psychopathy, personality disorders, autism spectrum disorders, ADHD or even learning disorders? I have always been fascinated by psychiatry as science and loved working with patients. Frankly, I came to forensic psychiatry because there were good research opportunities and plenty of time to spend with each patient, not because I was more interested in criminology than any other occasional reader of Agatha Christie. But somehow, I had to integrate criminal behaviours in the models I worked with. And some years ago, it dawned on me that the real object of our work lies there, hidden in plain sight. Persistent aggressive antisocial behaviour per se is the core phenotype that forensic psychiatry should put center stage, diagnose, understand from the perspectives of etiology, comorbidity and longitudinal development, and learn to prevent and treat.

Persistent aggressive antisocial behaviour indeed seems a highly promising phenotype for research. In its prototypical form, it has an early onset (it may be recognized sometimes between 3 and 5 years of age according to the life-course persistent overt type described by Moffitt), clear genetic liability (about 65% of variance, Burt et al, 2009), high stability into adulthood (a majority still have aggressive antisocial behaviours as adults) and is observable and thus relatively easy to measure. There are interesting etiological hypotheses, such as associations with sex steroids and monoaminergic neurotransmission (e.g. the cerebrospinal fluid ratio between dopamine and serotonin metabolites), hypofunctioning in prefrontal cortex or limbic dysregulation, impulsivity and reactions to drugs. An adolescent-onset subtype is more related to psychosocial factors and has better prognosis.

Its epidemiology is actually well studied. The small subgroup of the population who have the early-onset form of persistent aggressive antisocial behaviour is responsible for the majority of violent crimes (the prevalence will vary across societies, but in modern Sweden, it is as low as 1%, Falk et al 2013). The male:female sex ratio is at least 9:1, maybe even 98:2 for the most aggressive types, and other known co-variates are substance abuse (type-2 alcoholism with early-onset, polysubstance abuse), ADHD and personality disorder. The group of aggressive children also grow up to account for considerable proportions of all psychiatric patients, being over-represented in every diagnostic category in adult psychiatry (Kim-Cohen et al., 2003, one of the most important papers ever published in psychiatry!). Märta Wallinius defended her PhD thesis on aggressive antisocial behaviour in 2012, and it is accessible here.

The Life History of Aggression (LHA) scale was developed by Brown and Goodwin (1982) for research in veterans displaying pathological aggression and self-harm, and has been further validated by Coccaro and co-workers (1997). It contains 11 items describing aggressive, antisocial and self-harming behaviours, each measured by frequency and yielding 0-5 points, thus giving a maximum score of 55, with three subscales for the different types of behaviours included. Scores have a left-skewed (thankfully!) but overall normal distribution, with clear pathology at about +2 standard deviations. The LHA may be used as an expert assessment or as a self-rating. We are currently investigating whether it can also be rated for a specific time-frame, thus measuring also changes in aggressive behaviour.

There are also numerous scales measuring traits related to aggression, such as aggressiveness, anger, impulsivity and so on, but I think that it is important to keep the phenotype definition behavioural, as this will be much more reliable and clinically relevant. In forensic psychiatry, we really cannot be too preoccupied with people's feelings of anger, it is the behaviours that have to change.

Some individuals with persistent aggressive antisocial behaviour may be happy with their behaviour style as it is. In these cases, psychiatry will have little to contribute and it seems best that the penal system is left to do its job undisturbed by medical opinion. But in my experience as a doctor in correctional facilities of different kinds, the vast majority of antisocially aggressive persons are profoundly unhappy about how they constantly screw up their relationships, life plans and dreams. They would be more than happy to test various forms of treatments, be they pharmacological, physical, psychological or educational. And if an intervention would help some tens of percents of affected persons to refrain from half of their future violent crimes, a very significant reduction in societal violence at large might be achieved. With enormous positive health effects at large. 

Why  did it take so long for me too relaize this stunningly simplicit model? And why is this promising phenotype obscured in ratings of controversial diagnoses like psychopathy, conduct disorder or antisocial personality disorder? I think that the answer is simple and a bit humiliating for forensic psychiatry. Persistent aggressive antisocial behaviour is too simple, too obvious, not enough psy-whatever and is difficult to make a big fuss about. There is little money or prestige involved for the expert assigning this diagnosis or from creating diagnostic instruments and specialist training to recognize it. So therefore we have chased illusional diagnoses instead of finding a way to help people stop being aggressive with each other outside of those situations when physical aggression can be pro-social: in sports with clear rules and in tasks contributing to societety's legally regulated monopoly of violence. There is an urgent need for controlled treatment studies with reduced aggressive behaviour as primary end-point, and this should be the primary goal for forensic psychiatric research. 

Postmodernism

This post is the first in a series that will run in the blog at weekly, or something like weekly, intervals, called ”Dilettantischer Dienstag” (dilettantish Tuesday). In it, I will develop ideas, topics and interests that are not in my field of expertise, but rather somewhere in my general reading or geeky special interests. Some may think that this is not limited to Tuesdays, but those will at least be the days when these pieces are posted. And, let me remind you that on Fridays, a more serious series called Forensic Fridays will include texts from my actual field of expertise (even if this is certainly no guarantee of infallibility). 

The first dilettantish post will address a somewhat controversial and not too easy subject: the term “postmodern” or “postmodernism”. I have noted that these are now commonly used to denominate a senseless relativism of knowledge, rooted in sloth and misguided egalitarianism. Maybe this has to do with a current faibelesse for "hypermodernism" that Gilles Lipovetsky has sharply described (more on that later). 

In several papers and speeches over the years, I have, however, used the term "postmodernism" to highlight specific aspects of epistemology or ethics (sometimes to the dismay of anonymous peer-reviewers) and often cited with great appreciation the works by Pat Bracken and Philip Thomas on “Postpsychiatry” or “Postmodern psychiatry” (http://www.bmj.com/content/322/7288/724, also a monograph in the Oxford series on Philosophy and Psychiatry, http://www.amazon.co.uk/Postpsychiatry-Postmodern-International-Perspectives-Philosophy/dp/0198526091). Therefore I will briefly try to remind you about its original and – I believe – still valid use. These texts come from a paper I published in Swedish in 2011 (the excerpts are not at all original of course, but hopefully of some educational value) and may be found here http://celam.gu.se/digitalAssets/1481/1481973_postmodern-psykiatri.pdf . 

In 1979, Jean-Francois Lyotard described his time as the ”postmodern condition”, not as a “movement” or a programmatic –“ism”, but as a condition characterized by skepticism towards “meta-narratives - sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”. 

Postmodernity therefore does not entail nihilism in relation to knowledge or relativism. Instead, awareness of epistemic frames (which questions can be answered by a certain method) leads to more rigorous science. “Grand narratives” form obstacles to understanding what new information really means and lure us into drawing conclusions that are not founded in the scientific data or into extrapolating interpretations to contexts where they are not relevant. They also create artifactual conflicts between different perspectives and make it more difficult to see that knowledge is generated in “cuts” through reality, dependent on the perspective from which a phenomenon is examined, and that different contributions, as long as they are, each and every one, rigorous and epistemologically consequent, can be used as complementary rather than excluding.

I will continue to use these terms and hope to elicit some further interest for the issues at stake. 

The original Swedish quotes from the paper:

År 1979 beskrev Jean-Francois Lyotard sin samtid som det ”postmoderna tillståndet”, alltså inte som en ”rörelse” eller ”-ism” med ett program, utan som ett tillstånd präglat av skepsis mot ”meta-narratives – sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”.

Postmodernitet behöver inte innebära kunskapsnihilism eller relativism. Medvetenhet om kunskapsteoretiska ramar (”vilka frågor kan denna metod besvara?”) leder istället till en mer rigorös tolkning av vetenskap. ”Stora berättelser” hindrar oss från att förstå vad ny information egentligen betyder och lockar oss att dra slutsatser utan stöd i det vetenskapliga underlaget eller att extrapolera tolkningar till sammanhang där de inte är relevanta. De skapar också artefaktiska motsättningar mellan olika perspektiv, och gör det svårare att se att kunskap genereras i olika ”snitt” genom verkligheten beroende på ur vilket perspektiv fenomen undersöks, och att olika bidrag, så länge vart och ett är rigoröst och kunskapsteoretiskt konsekvent, därför är komplementära istället för exkluderande.

My thoughts on forensic psychiatry (from March 2014)

My research largely addresses the importance of neuropsychiatric problems on our ability to take responsibility for how we act, how we relate to others and to something or someone to give our lives meaning (our ‘character’). This text is an excerpt from my researcher's presentation at the CELAM website (http://celam.gu.se/people/henrik-anckarsater/).

Today, we know that risk factors and protective factors can be found in our genes, in brain development and in the biochemical/physiological processes that interact with our mental processes. Research has established probabilities resulting from many different factors, rather than causation in the classic (mechanistic) sense. Life is thus unfair in the sense that we must contend with different predispositions--and of course relate to different environments. Some of us find it easier to mature as individuals than others, as well as refraining from violence.

In addition, habits and learned patterns further restrict our freedom, and our knowledge about the consequences of our actions is incomplete. Therefore it is important that we as health care professionals meet people without preconceived notions about what they can and cannot be held accountable for. The role of the doctor is to restore health and thus the conditions for accountability.

However, this does not mean that science has excluded that thoughts or intentions may affect the body and physical actions in the world. Patients who believe they are receiving treatment for Parkinson’s disease show an increase in dopamine release in the brain, even if no treatment is given. The world is changed by ideas. We all know that willpower is essential to cope with challenges, that thoughts can provide courage when faced with fear, that love must be given freely and that we are expected to be held responsible for the way we act, vote and conduct businesses.

The interplay of brain, senses and soul that creates a person remains a mystery that science has been unable to explain. Yet we have reason to believe that these are aspects of the same phenomenon (‘neutral monism’).

But this image has not been, and is not, consistent with the current view in forensic psychiatry. Instead, the specialty builds on the assumption that humans are materially motivated according to the laws of nature. Therefore, forensic psychiatry has either advocated for criminal law legislation devoid of the metaphysical (of concepts such as competence, responsibility and punishment as a way to atone for the guilt of a crime), with protection of society and treatment as the sole objectives, or for a compatibilist model in which the person is held accountable, even if it is believed that (s)he was unable to have acted otherwise.

Sweden went further in this direction than any other country with the 1965 introduction of the Criminal Code, which replaced the old Penal Code with a series of ‘sanctions’ to various types of ‘care’ (prison, forensic psychiatric care, probation, juvenile care, etc.). Today everyone seems to agree that this system has not functioned as intended, and that it should be replaced.

I believe that we would be well advised, prior to the upcoming revision of the Criminal Code, to exercise restraint in ‘translating’ psychiatric knowledge into law, since these two fields have different points of departure: one wants to eliminate the causes of ill health, and the other wants to hold people accountable for bad actions they intentionally commit.

What we as doctors can comment on with certainty in courts of law is the lack of alertness, orientation and clarity (disturbances in the thought processes). Such impairments may be due to mental or physical illness and may have ‘destroyed’ the ability to act responsibly. In such cases (for example, in severe confusion or dementia), just about anyone can understand what has happened and it is difficult to see how any intent has arisen in a legal sense.

However, when doctors assess thought content, assessments become much more uncertain (as we have seen in court cases garnering media attention, such as that of the Norweigian terrorist Anders Behring Breivik).

If future Swedish law assumes that responsibility is the norm and limits the opportunity to obtain special criminal treatment for clear cases in which the ability to act responsibly has been destroyed (as in current international law), more people with mental illnesses will be sent to prison. This scenario would in turn result in higher demands for flexibility in implementation, which must include care and opportunities to finish the sentence in open forms.

The challenge is twofold: to accept the need for a well-functioning rule of law while offering all proper care as needed. A person may be psychologically disturbed, in need of care and accountable for their actions, all at the same time. It is even the norm in the justice system, where most prison inmates require various care interventions. As psychiatrists, our mission is to provide care, develop knowledge and propose changes to make justice more therapeutic (‘therapeutic jurisprudence’), but not to take over responsibility from lawyers or to naively translate our knowledge into their field.

When we conduct research about people, we work in different epistemological frameworks, which have different premises to respond to different questions. For example, brain imaging studies can show the appearance of brain activity while lifting an arm, but cannot answer the question of whether lifting the arm was a good idea.

We must work to rigorously interpret scientific knowledge within these epistemological frameworks. Forensic psychiatry has often extrapolated results from a methodology that answers questions that address an entirely different aspect of human behaviour (‘Charlie didn’t break the window, it was his ADHD that did it’ or ‘if he had a brain tumour, you wouldn’t think he was to blame’ even though most people with ADHD or brain tumours do not commit crimes).

The relationship between mental disorders and physical aggression is not simple to untangle. The majority of all violent crime in society is committed by a small group (1% of the population), almost always men who started to behave violently early in life and continued to do so. They have also had problems with hyperactivity, impulsivity and/or abuse. This group is also overrepresented in every diagnosis group within psychiatry, but the distinction between ‘chicken and egg’ is unclear.

People with psychoses are at greater risk of committing crimes, but this is due to a sub-group of people who also had early behavioural problems and progressed to abuse and crime. Genuine ‘acts of madness’ among previously non-violent individuals are extremely rare and essentially impossible to predict, since they tend to occur either early in the course of disease (when they can be bizarre and directed against strangers) or late, often directed at family members and without specific warning signs.

A central task of forensic psychiatry has been to carry out risk assessments of individuals who may be prone to violent acts. Recent research has shown that such assessments are based entirely on a combination of earlier behaviour with age at onset, substance abuse and gender. It has not been possible to show that any specific psychiatric factors increase accuracy beyond the prediction achieved by the above data. Therefore, I think we as health care personnel must refrain from speculating about long-term risk.

However, our mission is to help people who have or are about to develop patterns of antisocial aggression and to try to prevent violent acts through a here-and-now perspective. The most important step toward this end is to develop methods of breaking the pattern of early violent behaviour in children and adolescents, while helping them to avoid substance abuse and marginalization. To achieve this goal, schools must offer an environment free of violence, where the law is upheld and where it is just as obvious that children are not allowed to hit one another as it is that adults are not allowed to hit them. For those who wish to learn to use violence, options include sports and activities within the societal monopoly on violence. If specially trained school police officers are necessary to secure a good environment for children and to ensure that fighting and threats of violence do not become a ‘winning strategy’, then we must raise this discussion.

In recent years a new and rather unexpected problem has arisen at the juncture between psychiatry and law. The results from various studies suggest that current psychiatric diagnoses may not be supported by scientific reasoning. Consensus between different assessments is much less than we thought. The same risk factors and biomarkers seem to give rise to completely different problem complexes in different people. Almost no patients have a ‘pure’ diagnosis, but many diagnoses are made on a case-by-case basis and regularly change with each new care provider. Medications often affect many different problems and, with few exceptions, are not specific to any particular diagnosis. In 2013 there was even talk in the journal Nature that addressed psychiatric theory, comparing it to a broken airplane in the air requiring ‘in-flight’ repair. I think we must take this very seriously with a humble approach to new scientific findings if we are to maintain credibility in our specialty.

To sum up, I believe that forensic psychiatry should focus on treatment of those individuals who actually want treatment, starting by clearly defining problems instead of using diagnoses: assess patterns of aggressive antisocial behaviour, psychosocial dysfunction and/or suffering, and then without bias work with scientifically identified biological, cognitive, affective, behavioural and social risk and protective factors. It is encouraging that aggressive antisocial behaviour is a clinically meaningful, somewhat stable and recognizable problem complex for which neuroscientific studies and therapeutic research hold promise.

I have written my ideas as of March 2014 in this text as simply and clearly as possible. I have not backed the arguments with references, but should anyone who reads this online wish to discuss any of the points in the text and share any publications that either support or conflict with my ideas, please feel free to contact me by email, and perhaps such correspondence can be developed into a blog post about forensic psychiatry.

Mina idéer om rättspsykiatri (från forskarpresentation mars 2014)

Mina forskningsprojekt handlar i stort sett om betydelsen av neuropsykiatriska problem för vår förmåga att ta ansvar för hur vi handlar, förhåller oss till andra och till något eller någon som ger våra liv mening (vår “karaktär”). Denna text kommer från min forskarpresentation från CELAMS hemsida (här).

Idag vet vi att det finns risk- & skyddsfaktorer i våra gener, i hjärnans utveckling och i biokemiska/fysiologiska processer som samspelar med våra mentala processer. Det forskningen har belagt är sannolikheter mellan många olika faktorer snarare än orsakssamband i klassisk (mekanistisk) bemärkelse. Livet är alltså orättvist såtillvida att vi har olika dispositioner att leva med - och förstås olika miljöer att förhålla oss till - och vissa har lättare än andra att mogna som personer, inklusive att avhålla sig från våldsbrott.

Dessutom minskar vanor & inlärda mönster ytterligare vår frihet, och vi har bara ofullständig kunskap om konsekvenserna av vårt handlande. Därför är det viktigt att vi som hälso- och sjukvårdspersonal möter människor utan uppfattningar om vad de kan “rå för” eller inte. Läkarens mål är att återskapa hälsa och därmed förutsättningar för ansvarstagande.

Men detta innebär inte att vetenskapen har bevisat att tankar eller avsikter inte också kan påverka kroppen och fysiska handlingar i världen. Om man tror att man får behandling mot Parkinson’s sjukdom ökar dopaminfrisättningen i hjärnan även om ingen behandling givits. Världen förändras av idéer. Vi vet alla att det krävs viljestyrka för att klara svåra saker, att tankar kan ge mod även när man är rädd, att kärlek måste ges frivilligt och att vi gör affärer, röstar och agerar på ett sätt som vi förväntas stå till svars för.

Hur hjärnan, sinnet och själen samspelar till att skapa en person är ett mysterium som vetenskapen inte kunnat förklara. Ändå har vi skäl att tro att de är aspekter av samma fenomen (“neutral monism”).

Men denna bild har inte varit, och är inte, den gängse inom rättspsykiatrin. Istället har specialiteten byggt på antagandet att människan är materiellt orsakad enligt naturlagarna. Därför har man antingen förespråkat en brottslagstiftning fri från metafysiska begrepp (som tillräknelighet, ansvar och straff som ett sätt att sona skulden för ett brott), med samhällsskydd och behandling som enda mål, eller en “kompatibilistisk” modell där människan hålls ansvarig trots att man inte tror att hon kunde ha handlat annorlunda.

Sverige gick längre i denna riktning än något annat land när Brottsbalken infördes 1965. Då ersattes den gamla Strafflagen med en rad “påföljder” till olika former av vård (kriminalvård, rättspsykiatrisk vård, frivård, ungdomsvård osv.). Alla verkar idag överens om att detta system inte fungerat som det var tänkt, och att det bör bytas ut.

Jag tror att vi inför en kommande revision av Brottsbalken gör klokt i att vara återhållsamma med att “översätta” psykiatrisk kunskap till juridik, eftersom de båda verksamheterna har helt olika utgångspunkter (den ena vill eliminera orsaker till ohälsa, den andra ställa människor till svars för dåliga handlingar som de begått uppsåtligen).

Det vi som läkare kan säga något säkert om i domstolar är bristande vakenhet, orientering och klarhet (störningar i tankeprocesserna). Sådana nedsättningar kan bero på psykisk eller kroppslig sjukdom och kan ha “förstört” ansvarsförmågan. Det har då skett på ett sätt som egentligen vem som helst kan förstå (som vid svår förvirring eller demens), och det är svårt att se hur det i dessa fall kan finnas ett uppsåt i juridisk mening.

När läkare däremot bedömer tankeinnehållet blir bedömningarna mycket mer osäkra (som vi sett i massmedialt uppmärksammade rättsfall, till exempel Breivik).

Om en framtida svensk lagstiftning utgår från att ansvar är det normala och begränsar möjligheten att få straffrättslig särbehandling till uppenbara fall av ”förstörd” ansvarsförmåga (som det fungerar i internationell rätt redan idag) kommerfler personer med psykisk ohälsa att dömdas till fängelse. Detta skulle i sin tur skulle medföra ökade krav på flexibilitet i verkställigheten, som måste kunna innefatta vård och möjligheter att avsluta påföljden i öppna former.

Utmaningen är att hålla två tankar i huvudet samtidigt: acceptera behovet av en välfungerande rättsstat och samtidigt erbjuda alla god vård efter behov. En person kan vara både psykiskt störd, i behov av vård och ansvarig för sina handlingar. Detta är till och med det normala i rättssystemet, där de flesta intagna på fängelser behöver olika vårdinsatser. Som psykiatriker är vårt uppdrag att vårda, ta fram kunskap och föreslå förändringar som gör rättsskipningen mer terapeutisk (“therapeutical jurisprudence”), men inte att ta över ansvar från juristerna eller naivt översätta vår kunskap till deras fält.

När vi bedriver forskning om människan arbetar vi inom olika kunskapsteoretiska ramar, som har olika förutsättningar att svara på olika frågor. Till exempel kan hjärnavbildningsundersökningar visa på hur aktiviteten i hjärnan ser ut när man lyfter sin arm men inte svara på frågan om det var bra att lyfta på armen.

Vi måste arbeta för att tolka vetenskaplig kunskap rigoröst inom dessa kunskapsteoretiska ramar. Rättspsykiatrin har ofta extrapolerat resultat från en typ av metod för att svara på frågor som rör en helt annan aspekt av människan (“Kalle pangade inte rutan, det var hans AD/HD som gjorde det” eller “om han hade en hjärntumör skulle man ju inte tycka att han rådde för det”, utan att tänka på att de allra flesta personer med AD/HD eller hjärntumörer inte begår brott).

Sambandet mellan psykiska störningar och våldsbrott är inte enkelt att reda ut. Majoriteten av alla våldsbrott i samhället begås av en liten grupp (1 % av befolkningen) som nästan alltid är män som börjat bete sig våldsamt tidigt i livet och fortsatt med det. De har också haft problem med överaktivitet, impulsivitet och/eller missbruk. Denna grupp är också överrepresenterad i psykiatrins alla diagnosgrupper, men vad som är “hönan eller ägget” är oklart.

Personer med psykoser har en överrisk att begå brott men detta beror på att en undergrupp har haft tidiga beteendestörningar och fortsatt med missbruk och kriminalitet. “Äkta vansinnesdåd” hos tidigare icke-våldsamma personer är extremt ovanliga och i princip omöjliga att föutse, eftersom de tenderar att komma antingen tidigt i sjukdomsförloppet (då de kan vara bisarra och riktas mot främlingar) eller sent, och då ofta riktade mot anhöriga och utan särskilda varningstecken.

En central uppgift för rättspsykiatrin har varit att göra farlighetsbedömningar. Nyare forskning har visat att dessa i princip helt bygger på att kombinera tidigare beteenden med debutålder, missbruk, ålder och kön. Det har inte gått att visa att några särskilda psykiatriska faktorer kan öka träffsäkerheten utöver vad dessa uppgifter säger. Därför tycker jag att vi som hälso- och sjukvårdspersonal skall avstå från att “spekulera” om risk på lång sikt.

Däremot är det vår uppgift att hjälpa personer som har eller är på väg att utveckla mönster av antisocial aggressivitet och att försöka förhindra våldshandlingar med ett här-och-nu perspektiv. Det viktigaste steget i detta är att utveckla metoder för att bryta tidiga våldsbeteenden hos barn och ungdomar, och hjälpa dem att inte utveckla missbruk och social marginalisering. För detta måste skolan vara en våldsfri miljö, där lagen upprätthålls och det är lika självklart att barn inte får slå varandra som att vuxna inte får slå dem. Vill man lära sig att använda våld finns idrott och verksamheter inom samhällets våldsmonopol. Om det behövs särskilt utbildade skolpoliser för att trygga barnens miljö, och se till att det inte blir en “vinnande strategi” att slåss eller hota med våld, måste den diskussionen tas.  

Under de senaste åren har ett nytt och ganska oväntat problem tillkommit i mötet mellan psykiatri och juridik. Resultat från olika undersökningar talar för att dagens psykiatriska diagnoser inte “håller” vetenskapligt. Samstämmigheten mellan olika bedömare är mycket lägre än vad vi trott. Samma riskfaktorer och “biomarkörer” verkar kunna ge upphov till helt olika problembilder hos olika personer. Nästan inga patienter har en “ren” diagnos utan många diagnoser ställs vid varje tillfälle och byts regelmässigt vid nya vårdkontakter. Läkemedel påverkar ofta många olika problem och är med få undantag inte specifika för någon viss diagnos. Under 2013 talade man till och med i tidskriften Nature om att psykiatrins teoribygge är som ett trasigt flygplan i luften som måste repareras “in-flight”. Jag tror att vi måste ta detta på största allvar och förhålla oss ödmjukt till de nya vetenskapliga rönen om vi skall bevara förtroendet för vår specialitet.

Sammanfattningsvis tycker jag att rättspsykiatrin skall fokusera på behandling för personer som själva vill ha behandling, börja i konkreta problemdefinitioner istället för diagnoser: skatta mönster av aggressivt antisocialt beteende, psykosocial dysfunktion och/eller lidande, och sedan förutsättningslöst arbeta med vetenskapligt identifierade biologiska, kognitiva, affektiva, beteendemässiga och sociala risk- och skyddsfaktorer. Uppmuntrande är att aggressivt antisocialt beteende är en kliniskt meningsfull, någorlunda stabil och igenkännlig problembild som är lovande för neurovetenskapliga undersökningar och behandlingsforskning.

I denna text har jag skrivit ner mina idéer i mars 2014 så enkelt och klart jag kunnat. Jag har inte underbyggt argumentationen med referenser, men om någon som läst detta på nätet vill diskutera någon punkt i texten och ta del av publikationer som stöder eller problematiserar mina tankar är Ni välkomna att kontakta via mail, så kanske sådan korrespondens kan utvecklas till ett bloggsamtal om rättspsykiatrin.