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.
