Mad, bad or maybe merely human

Peter Kinderman

Is a mental health diagnosis
necessary to avoid prison?
Photo: Liam Quinn

The British Psychological Society’s report ‘Understanding Psychosis and Schizophrenia’ has challenged many commonly held beliefs about serious mental health problems. While the report has been widely welcomed, it has also prompted questions, particularly focusing on the report’s key recommendation that we move beyond seeing distress as a symptom of disease:

‘services should not insist that people accept any one framework of understanding, for example the idea that their problems are symptoms of an underlying illness’. 

This issue has been addressed on this site on a number of occasions and it’s clearly one that arouses strong feelings. The disease-model of modern psychiatry views emotional distress as the result of illnesses or disorders. Treating such problems in this way, as healthcare issues, is often seen as essential for ensuring that people get the help they need, and vital in avoiding inappropriate treatment.  In particular, some colleagues have suggested that viewing people as ‘mentally ill’ prevents them being blamed for actions for which they are not responsible. Rather than being seen as bad you can be mad (or more accurately sick) and more likely to be treated rather than simply punished.  Removing this protection (the argument continues) may even result in people being sent to prison inappropriately. These are clearly serious concerns and deserve careful consideration.

 The services you need - Care

No matter how often it’s advanced, the idea that a diagnosis ensures that people get the services they need, fails at the first hurdle. Despite the epidemic of psychiatric diagnosis, people with mental health problems are clearly already failing to get the help they need. In the UK, even the Government Minister responsible has suggested that mental health services are ‘stuck in the dark ages’. The quasi-independent Schizophrenia Commission has stated that ‘the message that comes through loud and clear is that people are being badly let down by the system in every area of their lives’.  In other words, the current system is failing, and something different is needed.

So how do we ensure that people with obvious and quantifiable needs (themselves intimately associated with their social circumstances) get the help they need without the use of diagnosis? The answer is in the question – we need to address identified problems rather than hypothetical ‘illnesses’. It isn’t complicated: we can operationally define, measure, research, understand and offer help for the specific problems that people identify. Perhaps even more importantly we can also broaden our focus, from individuals to the social challenges that give rise to these problems. We can offer practical help, negotiate social benefits (which could be financial support, negotiated time off work, or deferred studies, for example), or offer psychological or emotional support. There no need to maintain that people are ‘ill’: attention to people’s real problems will offer the most straightforward route to getting them the services they need.

The services you don’t need – Prison

So what about the charge that failing to identify distress as illness may result in inappropriate blame and even jail?

The relationship between mental health and criminal justice, particularly imprisonment, is indeed something that we urgently need to think about. The majority of people with mental health problems are neither criminal nor violent, although there is a complex relationship between substance use, mental health and criminal offending. Perhaps because of that complex interaction, it’s also been estimated that up to 90% of the UK’s prison population has some form of mental health problem (with comparable figures in the US). This suggests that the dominant medical model has not kept people with mental health problems (who do not tend to be violent) out of jail.

Having said that, it is important to understand how mental health issues relate to criminality. Clearly the relationship is complex: it simply doesn't follow that, if you commit a crime and also meet the criteria for a recognized mental disorder, then you can’t be found guilty or sent to jail. To take one simple example; a very large number of people are in prison for drugs offences, and their difficulties with substance use have been recognized and discussed in their trials, often cited as motives for acquisitive crimes. Once sentenced, people are (sometimes) offered interventions to address their substance use. But a diagnosis of ‘substance use disorder’ (a psychiatric condition listed in the diagnostic manuals) simply does not result in people avoiding prison. In truth, holding people responsible for their behaviour is a necessary cornerstone of civil society. Equally, our criminal justice system must take appropriate account of people’s personal and social circumstances. I’m not saying we should ignore people’s very real mental health problems and their possible relationship with offending. But I am saying that a diagnostic ‘disease model’ does not, in practice, help very much. Instead, we need to understand a little more about the functional relationship between mental health and personal responsibility.

Who (or what) is to blame?

Issues of free will and personal responsibility have been the subject matter of philosophy for over 4,000 years, and currently exercise jurisprudence, criminology, sociology, neuroscience, and politics as well as psychology and psychiatry. Simple solutions are unlikely. It is clear, however, that the invocation of a ‘mental illness’ is a non-solution to the problem. The traditional argument seems to be that, if somebody with a diagnosed mental health problem commits a crime, then the illness ‘made them do it’. This argument seems superficially to address various issues: if we blame the illness, we don’t have to respond punitively to a person in crisis, and if we cure the illness, we solve the problem. Then the individual can be offered medical care rather then a criminal justice solution.

But this is a simplistic and often unhelpful response. The notion of mental illnesses as entities separable from our social and cultural normative values is a myth. It is a circular argument to identify some aspects of our psychological functioning as ‘illnesses’ and then accord special legal status to them. Moreover this argument is applied inconsistently. The fact that a large proportion (perhaps the majority) of people in the criminal justice system have identifiable mental health problems suggests that, in most cases, these ‘illnesses’ have not, in fact, accorded them special status. At the same time, it’s equally clear that the vast majority of people whose problems do meet the diagnostic criteria for identified mental ‘disorders’ are perfectly able to take responsibility for their decisions, even those related to possible criminal activity.

But if the notion of ‘mental illness’ fails, in truth, properly to address the challenges of the relationship between psychological problems and criminality, what’s the alternative?  How should we think about these issues? How can we ensure that people get the help they need and that they don’t get sent to prison when it’s not appropriate?

As in any other situation, people should receive the help they need for their identifiable problems. There’s no need to invoke the notion of ‘illness’ to achieve this – we don’t invoke this concept in other areas of civic society: housing, education, financial help, etc. And we don’t need the notion of illness in order to protect people from inappropriate legal sanctions. In criminal proceedings, we should have the maturity as civilized societies to take all of the relevant psychosocial aspects into account when choosing sentencing options. There is no need to invoke ‘illnesses’ for Courts to understand, and take account of, the psychological and social issues that influenced a person’s behaviour and their state of mind at the time of an offence.

What would be wrong with a model of psychological well-being which accepts that biological, social, and circumstantial factors impact on our actions? In other words, extreme circumstances can affect our judgement. When Courts take account of these issues - for instance, when sentencing someone for a crime - people are presumed to have personal responsibility unless it can be demonstrated otherwise, but the criminal justice system can be flexible. We should set clear and robust criteria for such decisions, and we should use established rules for both legal and scientific evidence. We need scientific expertise to guide the criminal justice system through the complex relationships described earlier. But we don’t require the notion of illness.

So…

So how can we ensure that people with obvious and quantifiable needs get the help they need, including for the social problems that often gave rise to the difficulties in the first place, and avoid inappropriate entanglement in the criminal justice system? For those of us promoting a psychosocial approach, the answer is clear. We need to identify each person’s specific needs and offer them appropriate services. We need to identify the social challenges that give rise to these problems, and work to address them. By appreciating how such factors have impacted on person’s psychological well-being, we would also be able to determine the extent to which their ability to make rational, responsible, decisions have been compromised. Such a determination should be part of any Court’s adjudication, So do we really need the idea of illness?