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.