In lieu of an abstract, here is a brief excerpt of the content:The Tyranny of the BureaucratsSimon Wilson (bio) and Gwen Adshead (bio)Keywordsviolence, mental health, bureaucracyWe are grateful for the opportunity to respond to the two kind and thoughtful commentaries on our paper. Sadler suggests irrationality may be the key to distinguishing psychiatric from nonpsychiatric violence. We are not so sure that this is necessarily as helpful as it might at first seem. Who gets to decide what is rational? Much (...) “normal” violence, committed in the heat of the moment, impulsively, and drunkenly, may not appear that rational, even to the perpetrator, in the cold light of day. We are not sure one would wish to bring this sort of violence within the province of psychiatric explanations. Likewise, a point we made in our paper: Even delusionally driven violence often has its own internal coherence and rationality within an irrational framework.We found much to agree with in McCallum’s commentary, and perhaps his alternative approach is more helpful. He proposes a more sociological model of understanding what is going on in these complex cases, one that starts with societal dividing practices. Our present times have been described as the tyranny of the bureaucrats. Professional approaches are devalued. Diagnosis is only relevant in terms of its bureaucratic utility in moving people from one category to another. Since the writing of our paper, the criminal law has changed further in England and Wales. The Criminal Justice Act 2003 brought with it new sentences of indeterminate detention for public protection for those offenders categorized as “dangerous.” The presence or absence of psychiatric disorder being largely irrelevant for these purposes. This would seem to fit nicely with McCallum’s analysis, and in principle rather takes the wind out of our sails when we argued about the discrimination against psychiatric violence—now a diagnosis is not necessary for the state to intervene in a probabilistic fashion to prevent future violence. Deciding between what sort of violence counts as psychiatric and what does not, does not have quite the same drastic differential effect on the individual as perhaps it did. Its importance is now, as predicted by McCallum’s model, more to do with bureaucracy: Which government department will be paying for the individual’s preventive detention (Department of Health or Ministry of Justice)? [End Page 75]Related ArticlesFeature Article: When Violence Becomes a Psychiatric SymptomCommentary: The Contingent Object of PsychiatryCommentary: Reasons CountResponse: The Tyranny of the BureaucratsSimon Wilson Simon Wilson is a Consultant Forensic Psychiatrist at the Maudsley Hospital and an Honorary Senior Lecturer at the Institute of Psychiatry, London, UK. He qualified at Leeds University and trained in psychiatry at the Maudsley Hospital. He was previously Consultant Forensic Psychiatrist at HM Prison, Brixton, UK. He has particular interests in prisons, philosophical, and ethico-legal issues in psychiatry. He can be contacted via e-mail at:[email protected] Adshead Gwen Adshead is a Forensic Psychiatrist and Psychotherapist. She works as a psychotherapist in a high-security hospital. She is a group analyst and researcher in attachment theory as it relates to offenders. She has a Master’s degree in Medical Law and Ethics, and is a founder member of the Philosophy Special Interest Group of the Royal College of Psychiatrists. She can be contacted via e-mail at:[email protected] © 2009 The Johns Hopkins University Press... (shrink)

Psychiatrists are increasingly expected to be involved in violence assessment, prediction, and prevention. For some psychiatrists this sits uncomfortably with their conception of themselves as doctors. Is violence (ever) a medical/psychiatric symptom? If so, what is the role of medicine/psychiatry in preventing violence? What are the consequences of an interventionist stance? We attempt to explore some of these questions in this paper.

Tankersley has provided an interesting collection of data about various groups of antisocial individuals. Is this a paper about the moral reasoning of psychopaths, or is it an attempt to address a philosophical question—whether moral behavior is primarily driven by emotions (moral sentimentalism) or by reasons (moral rationalism)—empirically? I think it attempts a little of both, although I concentrate on the latter. -/- The trouble with much of the literature on psychopathy is the terminological confusion, and Tankersley has not escaped (...) this. Several disciplines, with their own languages, have an interest in antisocial individuals and use similar sounding words in different ways. It is easy to get confused. Doctors make diagnoses. Antisocial (or dissocial) personality disorder is a medical diagnosis, and has a clear, operationalized definition. By virtue of being a disorder, it must result in some impairment in the functioning of the individual. Psychopathy is a psychological construct, not a diagnosis, and attempts to measure (in a reliable and valid way, using the Psychopathy Checklist) aspects of a person's mind particularly relevant to antisocial behavior. Psychopathy and antisocial personality disorder are different approaches to the same natural phenomenon, but they are not coterminous. There are many individuals with antisocial personality disorder who are not psychopaths. There are some individuals who are psychopaths who do not have any medical diagnosis (e.g., the so-called white collar psychopath). Psychopathy is not a subset of antisocial personality disorder (pace Tankersley 2011, and Herpertz and Habermeyer 2004). (shrink)