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.
