Twitter discussion on criminal responsibility

I have been very interested in the Twitter debate on compulsion and forensic patients. I should declare, to start, that broadly I have a psychodynamic and social psychiatric view of the mind. I don't believe that we deal with simple facts in Psychiatry, but rather concepts that should be problematised, and I had sympathy with anti-psychiatry long before I was a psychiatrist.

The concept that someone can be found to lack criminal responsibility due to mental disorder can be discussed without a priori assumptions about mental illness. Personally, I think the imperfect concept of mental illness can be useful - which is all it needs be, if we can remember that the map is not the territory.

Precision is, however, required in such a discussion. It is necessary to separate this argument from general thoughts about the link between mental disorder and offending to discuss both this and psychiatric disposals of criminal convictions. Of course, there are high rates of suffering and remarkable states of mind (which I call psychopathology) in remand and convicted prisoners. There are also high, but lower, lifetime rates of psychopathology in the general population.

It is easy to accept that a person can be in a very remarkable state of mind in which their beliefs are markedly at odds with all of those around them. In the recently-referenced blogs I have seen on this subject, no one seems to be suggesting that there is a problem with this idea, which is the idea of psychosis. Most importantly, people can be in that state, and then out of it. I think that, in a limited number of such circumstances, particular actions should be understood to be out of their control when they are in a state of psychosis.

There is rightly a situation where a person can be found to lack criminal responsibility for a specific action at a specific time, due to mental disorder. In Scotland, this is where the person is found, by reason of mental disorder, to be unable to appreciate the nature of wrongfulness of the conduct. This does not mean that the person is adjudged to have been generally lacking in criminal responsibility at the time. A person can still have been suffering psychosis and fully be aware of the nature and wrongfulness of their actions, or of one action but not another. That is, to me, the right model.

If someone is in distress, even in a state of psychosis, and hits someone because they are angry with them, there may be no case for saying they lacked responsibility. If someone hits someone believing they are Satan, and is otherwise expressing bizarre-seeming beliefs, appears hallucinated, and looks like others we have seen in the past who are psychotic, they probably should not be found criminally responsible for that act. It is a manifest public good to prevent these people from receiving a criminal conviction.

Where someone is found to have committed a serious crime, but to lack responsibility for it, it is our responsibility to our fellow human to try to bring them out of that state, even if they do not want that. I think it is legitimate of society to ask of them that they try to stay out of that state, when it has been a clear precipitant of a serious offence. That is why psychiatric disposals must remain.

To ignore the social as an essential part of the personal means to ignore an ineluctable fact of humanity. We exist in groups; we act in groups; we are born in a group and are socialised: one of those groups is society. We have a legitimate interest in one another's state of mind. Society should make accommodations for us, but we also must make accommodations for society - and we cannot escape that tension by denying the rights of the individual, or by denying the legitimate needs of society.

Projection Control

How do we find the courage to accept that enactments and projection and our own unconscious minds are part of the process of Psychiatry?

Room

Grave Colours Brightening

Alasdair Gray's 2010 collaboration with Pringle of Scotland is not wholly comparable to Gorbachev's advert for Louis Vuitton. But it is odd. I like it, though.

Rafael Viñoly

See the full gallery on Posterous

It was terrible - in terms of the British Constitution if nothing else - when Prince Charles's letter-writing got the Qatari Royal Family to drop Richard Rogers' design for Chelsea Barracks. Our Prince's desire to protect the loyal citizenry from those modernists like Lord Rogers, with their monstrous carbuncles, was not just over-reaching personal preference. It was symptomatic of a folksy merrie-old-England philistinism that infects this country still. Even Cool Britannia did not get rid of it.

I am so pleased, then, that Dundee is building something outstanding with the new V&A by Kengo Kuma. (http://VandAatDundee.com/your-future/PDF/KengoKuma_full.pdf) And Aberdeen is planning something bold - we don't know what yet - in Union Terrace Gardens.

Fortunately, Charles doesn't own all of London. Rafael Viñoly, a favourite architect of mine, whom I have drawn a sketch of in pencil, has designed something bold for 20 Fenchurch St in the City.

Cole Porter

Sitting in the car in Kincorth, waiting for Niamh to finish her reporter's incursion into the community council, I am listening to Cole Porter songs and have drawn a sketch of him in biro from a photograph of him on the Internet.

From "Let's Do It", I think the best lyrics of all the improbable lyrics are these:

Sturgeon, thank God, do it,

Have some caviar, dear.

In shady shoals, English soles do it,

Goldfish, in the privacy of bowls, do it,

Let's do it, let's fall in love.

Sent from my iPad

Two Ways of Thinking: An Introspective Observation

What kind of thought is this wooden guitarist having? Cognitive therapy, and the cognitive revolution in general, freed us from the limits of both psychoanalysis and behaviourism. Freud and Skinner each in their own way devalued the thought, which cognitivists think is ineluctable, revealing and valuable. However, it is not to devalue thoughts to say that they are not all equal qualitatively. It may be a brave step for a cognitivist to take, especially since is merely an untestable introspective observation.

Obviously, not all thoughts are created equal. Some are profound, coming at the expense of great psychic effort. Others are about dinner. The President of the United States' thoughts can influence war and peace; a hermit's may never influence another person directly. But even when dealing with the same issue, a person can have two dissonant thoughts without hearing the dissonance. Is that because one is "louder", or more valuable, or even more convenient? Not always, in my experience. Thoughts can feel different.

When an exam is coming, I know that I have it, but put off studying. In abstract: I have the thought of the impending exam, and the thought of the importance of studying, but fail to structure my activity around that second thought. It has value to me - I do not ignore it - but it fails to be an efficacious thought. Then, at some point, and without cue, I feel a great emotional desire and cognitive imperative to study. I already knew that I had an exam coming, but at that point I know it in a deeply affective way that structures my behaviour, not to mention holding my emotions and sympathetic nervous system in its thrall.

To me, that represents best my observation that thoughts exist in two ways: a superficial and purely cognitive way; and a deep, cognitive-affective way that structures other thought. I would call the former a superficial thought and the latter an embedded thought.

I have seen similar in my very limited exposure to patients with phobias, or even in patients who have insight into hallucinations. I wonder what literature addresses this phenomenon.