Microsoft word - the impact of psychiatric disorder on the environment.doc

DRAFT of chapter for The Impact of the Environment on Psychiatric Disorder (Hugh
Freeman and Stephen Stansfield eds), by John Adams, 8 August 2002
[This essay has not been published. It was rejected by the commissioning editors as
“not what they had in mind”. The much-delayed book was published in September
In research for the essay I discovered the heated debate about what to do with DSPDs –
people with Dangerous and Severe Personality Disorders. I have decided to post it on
my website in October 2006 in the hope that it might contribute to a debate that has
made little progress since it was written.]

Risk and the impact of psychiatric disorder on the environment

This chapter, in this book, raises a chicken and egg question. How do our (disordered?)
perceptions of risk influence the impact that we have upon our physical and social
environments, and how do they in turn impact upon us? Which came first is obscured by
the mists of time, and no longer matters. We influence our environment and it influences
Throughout the now vast literature on risk1 one finds frequent reference to the distinction
between “real”, “actual”, “objective”, “measurable” risks, and “perceived” risks. Those
making this distinction usually do so to in order to insist upon the superiority of the real
over the merely perceived. But it is a false distinction. All risks are perceptions. Risk is a
word that refers to the future. It does not exist except in our imaginations.
The falseness of the distinction is on display in an argument that, at the time of writing,
the Royal College of Psychiatrists is having with the British Government about proposed
reforms to the 1983 Mental Health Act and, in particular, as they relate to the
management of risks posed by people with dangerous and severe personality disorders
(DSPDs in the jargon of the debate). It is an argument that has many features in common
with many other debates about our relationship with our physical and social environment.
I will look first at the psychiatric argument, and then consider the light that it shines on
these other debates about our relationship with the environment.
Managing the risk of DSPDs
The Government says (Home Office and Department of Health 1999)
“It is our intention to put in place a co-ordinated package of arrangements that offer better protection to the public in a way which strikes the right balance between the interests of the individual and society.” 1 Not just vast but rapidly growing. Typing “risk” into the Internet search engine Google on 2 August 2002 yielded 21.2 million hits. Just two months earlier the same exercise yielded fewer than 19 million. This would appear to be an uncontentious aspiration, indeed one that the Government would also claim for all its efforts to protect us and our environment. The difficulty lies in the absence of a consensus about what constitutes “the right balance.” Figure 1, the Risk Thermostat, is a simple model that describes the process of risk management as a balancing act. It proposes that • everyone has a propensity to take risks; this is the setting of the thermostat • this propensity varies from one individual to another; some like it hot, others cool; no one I have met aspires to absolute zero. • this propensity is influenced by the perception of the potential rewards of risk taking;
the greater the perceived reward, the greater the temptation to take the chance • perceptions of risk are influenced by the experience of accident losses - one's own and
others'; the larger the risk – a combination of perceived probability and magnitude of consequence – the more careful one is inclined to be • individual risk taking decisions are balancing acts in which perceptions of risk are weighed against propensity to take risk. Propensity to
take risks
control .

jail, loss of control .
Accident losses, according to this model, are, by definition, a consequence of taking risks; to take a risk is to do something that has a probability of an adverse outcome; the more risks an individual takes, the greater, on average, will be both the rewards and losses he or she incurs. The model describes a process that might be called cost-benefit analysis without the £ or $ signs. It is a conceptual model, not a model that can be made operational by plugging in numbers; both the rewards box and the accidents box contain large numbers of doubly incommensurable variables – there is no single metric to which a given individual could reduce them, and their significance is perceived differently by every perceiver. Everyone involved in the management of those with dangerous and severe personality disorders – everyone from the disordered person him/herself, to the psychiatrist, social worker, Secretary of State for Health and members of the public – will have different perceptions of the risks and rewards involved. Control and loss of control are key variables. If someone is deemed (by whom we come to in a moment) to be “a significant risk to others” - they can be deprived of their freedom under the proposed changes to the Mental Health Act. They need not have committed a crime, merely deemed likely to. How likely? And with what consequence? The aspiration to “strike the right balance between the interests of the individual and society” begins to sound glib. Three kinds of risk
In addition to the great variety of risks and rewards hinted at in Figure 1, there is a further
set of distinctions to be made. The Venn diagram of Figure 2 proposes that there are
qualitatively different kinds of imaginings in the face of uncertainty.
Figure 2. Three types of risk.
e.g. cholera: needa microscope tosee it and a Most commonly encountered are directly perceptible risks. We all routinely monitor our environment for signals of safety or danger and respond (do the balancing act) as we judge appropriate. We judge gaps in the traffic before crossing the road, we sniff the mouldy food in the refrigerator (or, if lacking in confidence consult the sell/eat by date), we take an umbrella if it looks like it might rain, and we steer clear of the occasional ranting schizophrenic being “cared for” in the community. And we all duck if we see something about to hit us. But direct perception is not always sufficient. Scientists with microscopes can see dangers invisible to the naked eye. And statisticians, actuaries and epidemiologists can sometimes see probabilities of harm before they become manifest to our unaided senses. And psychiatrists can identify dangerous psychopaths such as the moors murderer Ian Brady and the Yorkshire Ripper Peter Sutcliffe – with the benefit of hindsight. But the Government, with its proposed reforms to the Mental Health Act, aspires to identify such people before they commit their crimes and here, sadly, it comes up against our third category, virtual risk. The Government concedes that “there is no consensus amongst clinicians on the nature of personality disorder, how it should be managed, or the extent of the role health professionals should be expected to play in dealing with those personality disordered people judged to be unlikely to respond to hospital treatment. This in turn reflects the lack of an adequate research base of evidence.” Despite this lack of consensus it insists that “The Government is determined to protect the public and provide effective services for dangerous severely personality disordered people. A new approach is needed to provide a focus on this group. The four essential elements of the framework the Government proposes are: 1. the creation of powers for detention and continued supervision of DSPD 2. the establishment of better means of identifying DSPD individuals and specialist assessment processes to inform decision making at different points; 3. the development of specialist approaches to the detention and management 4. the establishment of a comprehensive and continuing programme of research into the management of dangerous people with severe personality disorder to support development of policy and practice. The order in which these objectives are presented is important to an understanding of the opposition that they have provoked. First the Government intends to give itself new powers to detain DSPD individuals. Second it will seek to establish better means of identifying who these people might be. Thirdly it will try to improve the way it “manages” such people, once they have been detained. And finally it proposes a research programme to support the development of policy and practice. Shoot first and ask questions later? So why is the Government proposing to reform the Mental Health Act to permit it to lock up more people with a condition about whose nature the professions best qualified to comment cannot agree? The proposed reforms are being advanced to provide “better protection to the public” in a way that “strikes the right balance” between individuals and society. The implication is that the current balance is wrong, that society should have more protection and individuals less, and that the existing legislation stands in the way of this rebalancing. It says “The Mental Health Act 1983 requires that a person with psychopathic disorder should be assessed as being likely to benefit from treatment in hospital before they can be detained in hospital. “ A distinction is made between “mental illness” and “personality disorder”. The first is considered treatable, the latter not. Treatments, if not cures, are available for depressives, manic-depressives, and paranoid schizophrenics. But those with personality disorders are considered to be incurably bent that way; there is apparently no known pill or therapy that will cure a paedophile of his illicit urges. The Government notes that “People with personality disorder fall on a continuum from near normal behaviour to extreme disruption in personal and social functioning. The overwhelming majority do not pose a risk to the public and live reasonably ordered, crime free, lives. The small proportion of such people who do pose a risk often suffer from the type of personality disorder that manifests in serious antisocial behaviour.” Who will decide the point on this continuum at which a disorder becomes seriously antisocial? The Government proposes to establish “a new independent decision making body, the Mental Health Tribunal, which will obtain advice from independent experts as well as taking evidence from the clinical team, the patient and his or her representatives, and other agencies where appropriate.”(Home Office and Department of Health 2002) The promise that the new powers sought will be exercised with expertise and independence has left many unconvinced. The proposed reforms have led to the formation of the Mental Health Alliance (, a coalition of over 50 organisations2, including the Royal College of Psychiatrists, who share common concerns about the Government’s proposals to reform the Mental Health Act (1983). The main concern shared by all members of the Alliance is a lack of safeguards for detained patients. The Government’s consultation document on its draft Bill published in June 2002 (Department of Health 2002), contains the following dialogue. Will the concept of ‘treatability’ be retained?
2 Afiya Trust, AWAAZ, British Association of Social Workers, British Psychological Society, Community Psychiatric
Nurses Association, Critical Psychiatry Network, GLAD, IMHAP, Kings Fund, MACA, MDF, Mental Health
Foundation, Mind, POPAN, Rethink, Richmond Fellowship, Royal College of Nursing, Royal College of Psychiatrists,
SIRI, Turning Point, UKAN, UK Federation of Smaller Mental Health Agencies, Unison, United Response, US net,
Voices Forum, Young Minds
Associate members
ACHCEW, ACCI, Age Concern (England), Alcohol Concern, AWETU, British Deaf Association, Carers’ National
Association, Chorley and S. Ribble CVS, Church of England Board of Social Responsibility, Confederation of Indian
Organisations, Democratic Health Network (LGIU), Depression Alliance, Greater London Mental Health Advocacy
Network, Having a Voice, Justice, Kente, Mencap, NACRO, National Autistic Society, Race on the Agenda, RADAR,
Royal College of GPs, Sign, Social Action for Health, Somali Mental Health Project, WISH.
No. Under the present Act a significant number of people, with a primary diagnosis of personality disorder and who pose a risk to others, are not detained in hospital because of uncertainty as to whether treatment would be likely to alleviate or prevent a deterioration in their condition. The new legislation will not include a ‘treatability’ test. Is there separate legislation for those who are considered to have dangerous
severe personality disorder (DSPD) or are there specific provisions in this new

There is no separate legislation for “DSPD”. The term, which refers to the small group of people with a severe personality disorder who also represent a high degree of risk to the public, does not appear in the new Bill. People with personality disorders will be treated in exactly the same way as patients with other mental disorders and will come under compulsory powers if they meet the same conditions for compulsion. This removes a problem in the 1983 Act where the ‘treatability’ test prevents people with mental impairment or psychopathic disorder from being treated under statutory powers for their own benefit or to protect the safety of others [my italics]. This will no longer appear. What is being done to provide services to those who are considered to be

Service developments are not part of legislative proposals; they are part of the wider agenda to provide better mental health services for everyone. So, at the time of writing, the Government is proposing that people who are judged by “independent experts” – qualifications not specified – to lie a sufficient, unspecifiable, distance from “normal” on the normal/disordered continuum, and who have not done anything dangerous, but are judged by the independent experts to be likely to, can be locked up – even if the experts can suggest no treatment for their condition. On the 25th of June 2002, the Law Society and the Royal College of Psychiatrists, important members of the pool from which the Government might hope to recruit its independent experts, issued a joint response to the Government’s Consultation document. Amongst other things it said ( "The Law Society and the Royal College of Psychiatrists unequivocally reject the Government's current proposals for reform of the Mental Health Act 1983. In our opinion, the proposals are fundamentally flawed. … the criteria for compulsion have been so widened that large numbers of patients would find themselves inappropriately placed under sections of the Mental Health Act. … the proposals as they stand would introduce powers that are ethically dubious and practically unworkable …” The wider context
The Government is the nation’s foremost risk manager. This job - whether dealing with
transport, food, crime, pensions, pesticides, global warming or mental health – involves
“striking the right balance between the interests of the individual and society.” Whenever
it attempts to do this it discovers that there is no such thing as society, certainly no such
thing as a society in which everyone agrees about the nature of the risks and rewards that
it should seek to balance.
Our risk thermostats, individual and institutional, have perceptual filters (Figure 3). The
less directly perceptible, or scientifically ascertainable, the risks and rewards, the greater
the influence of these filters. The argument about the proposed reforms to the Mental
Health Act is an argument about a virtual risk – a risk about which there is no scientific
consensus. The Government attaches more importance to the reward of improved public
safety than to the risk of getting it wrong and depriving innocent and harmless people of
their freedom. The Mental Health Alliance weights these risks and rewards differently.
Figure 3
A risk thermostat
with perceptual filters
Propensity to
take risks
Figure 4 presents a typology of perceptual filters that has been applied to the participants in numerous such debates. The influence of these filters increases as we move from directly perceptible risks and rewards to the uncertainty we are calling virtual risk. The filters influence the management of all three types of risk. Even with clear and directly perceptible risks – such as those taken by a rock-climber clinging to a sheer face – the filters operate. His (it is usually a young man) perception of the risks and rewards that motivate his behaviour will be very different from that of his nervous mother. With invisible, and possibly non-existent risks, such as those associated with pesticide residues or low-level radiation, the filters will be all-determining. The typology presented in Figure 4 has been more fully described elsewhere3. It has been variously called a “typology of rationalities”, a “typology of social solidarities”, a “typology of perceptual filters” and “a typology of ethical filters”. Inextricably bound up with every rationality, solidarity or perceptual framework, one finds sets of moral principles and ethical codes that inform risk taking behaviour; ultimately, in the face of uncertainty, people do what they think is right in the circumstances. The characters in this typology: the Hierarchist, Fatalist, Individualist and Egalitarian all adhere to different “myths of nature”4 represented by the icons. The Individualist myth, the ball in the cup, stands for nature robust, benign and cornucopian; you can shake it about and the ball always comes to rest safely and securely in the bottom of the cup. The Egalitarian sees nature as everywhere fragile, ephemeral and threatened – as represented by the ball perched precariously on the overturned cup. The Fatalist sees nature as untrustworthy and unpredictable. The Hierarchist sees it as reliable and well-behaved within limits, but cautions against pushing the ball over the rim. 3 See Risk and Morality: three framing devices” 4 So called because each represents a partial truth, a paradigm, a view of the world often but not always consistent with reality, if we could but know it. The axes describe cultural dimensions associated with these myths. Toward the top one finds cultures dominated by rules, prescriptions and inherited status. Toward the bottom cultures become more flexible and democratic, negotiating the rules as circumstances develop. Toward the left one finds individualistic cultures and to the right cultures with a collectivist ethos. Like all models, Figure 4 is a simplification of a more complex reality, but the typology nevertheless captures not only significant differences in the way nature is perceived, but also significant differences of opinion about what constitutes moral behaviour both with respect to the physical environment and to those with whom we share it. Consider the problem of noise, a subject discussed in chapter 1. It is not possible to measure noise objectively. Noise is unwanted sound, and one person’s music can be another person’s noise. One can measure sound levels objectively but not the degree to which they are (un)wanted. Throughout its period of development and commercial operation Concorde has been opposed by an egalitarian (environmentalist) lobby. In addition to its cost to the taxpayer, its extravagant fuel consumption, its threat to the ozone layer, and the fact the price of a ticket would make it an elitist form of transport, objectors complained about the “noise” of its engines on take-off and landing. At the time of its first landing at Heathrow Airport the Anti-Concorde Project (of which I was member) stationed itself, with sound level recording equipment in Green Man Lane at the eastern end of the southern runway. Nearby in the same street was a van from the Department of Trade (a hiearchist according to the typology of Figure 4) with similar equipment. Also in the street were numerous other people who had come to witness the event. Since the Department of Trade measurers were secretive and tight-lipped, many people interested in the measurements gathered around us. It was clear that there were other objectors to Concorde, but that the majority were Concorde enthusiasts. For the purpose of comparison we measured the sound of a number of sub-sonic jets as they landed before Concorde, and then Concorde came over. A remarkable thing happened. The environmentalists clutched their ears, grimaced and some almost collapsed. The enthusiasts leapt in the air shouting and cheering. The (much higher) reading on our sound-level metre was irrelevant. To one part of the group it was the roar of progress. Its note the uplifting one of freedom and mobility and science in the service of Man. To the other part it was the thunder of technology gone mad, and its note the ominous one of civilization in retreat before the privileged off-shore jet-set. Once one starts looking for the types presented in figure 4 they start to acquire distinctive personalities (Figure 5). The Supporters of Friends of the Earth, Greenpeace and anti-Concorde environmentalists are typical egalitarians, worried about the damage that technology-assisted untrammelled self-interest is inflicting upon both nature and society. They are suspicious of the motives of both big business and big government. The CEO of a multi-national corporation flying across the Atlantic in Concorde, and those who aspire to, are typical individualists – along with gamblers, racing car drivers, venture capitalists and all those who mock green communards and complain about the Nanny State. And the Government, with its van full of sound level measuring equipment, is a classic hierarchist, hoping, usually in vain, to come up with numbers that will settle the argument between the fans of Concorde and its opponents. The voice of the fatalist is seldom heard; if he lives in a cheap bed-sit under the flight path he won’t like the noise, but will see no point in protesting because experience tells him that no one will do anything about it. Problems of communication and trust
The characters presented in Figure 5 have great difficulty in understanding each other
when discussing risk. They argue from different premises. The unfolding debate about
the reform of Britain’s Mental Health Act has coincided with the release of the film
Minority Report. The plot of the film mirrors the debate rather neatly. 50 years from now,
so the film relates, science will have developed the ability to anticipate who will commit
a crime, and when. Armed with this intelligence the law enforcement agencies of the state
(the hierarchy) arrest, and find guilty, and incarcerate people who were about to commit
crimes - which, leaving out the finding of guilt, is more or less what the reformed Mental
Health Act proposes to do. In the film the precogs (precognitives) who predicted the
crimes were never wrong – until, toward the end of the film, the possibility was
introduced that, on occasion, they might be.
The precogs in the film were the servants of a hierarchy that aspired to an orderly, crime-
free world. The dramatic tension in the film was generated by an exploration of this
aspiration and the exposure of its logical incoherence. The film played in an entertaining
way with the incompatibility of free will and predestination. If one knows that one is
predestined to murder someone, and knows the consequences of so doing, might this
knowledge deter one from committing the act? This question spills over into the more
general problem of the production of predictions (all risk estimates are predictions) that
will persuade adherents to a different paradigm. Were the doom-bearing prophets of
Limits to Growth in the 1970s wrong in their predictions of dire shortages and pollution
by the end of the century? Or might they claim that their predictions became self-
falsifying prophesies because they encouraged both individuals and governments to curb
their extravagant appetites? Or was it the case, as individualist advocates of free markets argue, that myriad responses to signals of impending scarcity fended off the predicted doom? Or might the interventions of wise and prescient governments deserve the credit? Or were the predictions simply wrong, confounded by an unpredictable reality? Or were the predictions right, and is the world now even closer to the cusp of catastrophe? In environmental debates each of these possibilities is blocked by some filters and gets through others. In Figure 1 science can cast helpful light on the connections between behaviour and consequence (the arrows connecting balancing behaviour to rewards and accidents) but, for reasons suggested by Figure 3, it is much less confident when dealing with the connections between consequence and behaviour. These connections must pass through the filters described by Figures 4 and 5. The Heisenberg Effect, whereby the act of measuring alters that which is being measured, confounds all attempts to produce objective measures of risk, with an added complication introduced by the variety of filters fitted to the measuring devices called humans. We do not respond blankly to uncertainty. We impose meaning(s) upon it. In the presence of virtual risk, what we believe depends on whom we believe and whom we believe depends on whom we trust. None of us is scientifically competent to judge all the risks with which the electronic and print media daily present us. Figure 6 presents the results from an English survey of trust; it records the percentage of respondents who said they would “often” or “always” trust institution X to “tell the truth about risks”. X referred to the Government, Companies, the media etc. (Marris, Langford, & O'Riordan 1996) • Least trusted were companies - at 9% - and the government - at 6%. These are the main producers and regulators of threats to the environment, and the people likely to have the most useful knowledge about them. • Most trusted are friends and family at 78% and 86%. Unfortunately these are the people least likely to have useful knowledge about threats to the environment. Figure 6 Expressions of trust and distrust are statements about perceived motives. Assuming that the views summarized in Figure 6 come from a representative cross-section of the English public5, the message is interesting. The motives of Government (hierarchists) and big business (individualists) are viewed with suspicion by the great majority; indeed in controversies such as Brent Spar and BSE government and big business were widely held to “be in bed with each other”. Environmental organizations (egalitarians) appear to have captured the popular moral high ground. Doctors are seen (mostly) as working in the interest of their patients. When the scientist category is unpacked, trust is revealed to be highest for those scientists working for environmental organizations, and much lower for those in the pay of government and big business. The relatively low position of trade unions probably reflects the view that they are defenders of narrow sectional interests rather than the wider public interest. The relatively lower levels of trust enjoyed by religious organisations possibly reflects a suspicion, in a secular age, of religious dogma and those who “spin” its message. And the lowly position of “the media” (there are numerous honourable exceptions) may reflect “risk fatigue” – a state of cynicism engendered by the popular media’s habit of sensationalizing every newly discovered virtual risk. The high levels of trust enjoyed by family and friends are noteworthy. It is unlikely that most respondents trust their families and friends to tell them the scientific truth about risks; few people have scientists amongst their families and friends competent to judge the science. It is more likely that these high scores are saying that they trust them 5 Figure 5 combines the results from two samples in Norwich: A – stratified by housing type (N = 127), and B – three groups: scouts, Chamber of Commerce and environmentalists (N = 70). not to lie. Perhaps Figure 5 has captured the ethical perspective of what might be called the fatalistic majority. According to this perspective • where the truth threatens profit, profit will prevail, • where the truth threatens the electoral prospects of government, government • you should place your provisional trust only in those who have no obvious motive for lying to you; you can only trust with confidence those whom direct personal experience tells you can trust.6 Lessons from psychiatry?
When Figure 5 was presented to a conference of psychiatrists convened to discuss the
prosposed reforms of the Mental Health Act some of them thought that they could
recognise their patients and began prescribing for them. The Egalitarian, deeply
suspicious of both big business and big government, was deemed paranoid, and
prescribed chlorpromazine. The irrationally optimistic individualist was considered
manic, and prescribed lithium. The poor sad Fatalist, buffeted by forces beyond his
comprehension and influence, was given Prozac. The psychiatrists did not instantly
recognise themselves as Hierarchists but that – as the putative definers of “normality”,
assessors of risk, prescribers of treatments, and supervisors of the untreatable, is the role
that they had been assigned - or assigned to themselves.
There was no agreement about what they might prescribe for themselves – although one
suggested alcohol.
The cultural theory types presented in Figure 5 are caricatures – real people are more
complex. But, with this caveat borne in mind, they are nevertheless useful caricatures.
They serve as simple, forceful reminders of the profound and persistent differences that
underpin concerns about risk. In an article in the Psychiatric Bulletin [REF 1999; 23:578-
581] about the proposed reforms to the Mental Health Act the people who were the focus
of concern, those with personality disorders, were referred to as “patients lacking
insight”. This is not a bad description of the more vehement participants in debates about
risks to the environment. Figure 7 adds an insight dimension to the typology of Figure 4,
suggesting that if one could rise above fray down on the ground below one might gain a
wider and clearer view of the perceptions and motives of all the others with whom one is
arguing and, just possibly, stand a better chance of understanding them.
6 In The Origins of Virtue, Matt Ridley describes the conditions necessary for altruism to flourish and concludes that a social scale sufficiently small for individuals to recognise each other is of central importance (Ridley 1997) – a worrying conclusion in a hypermobile world. Psychiatrists deal routinely with people who construe reality idiosyncratically, people who perceive threats that “normal” people cannot see. But the concept of normality can embrace a range of perceptual filters. Even where risks are clearly perceptible, either directly or with the help of science, it can be difficult for “normal” people to reach a consensus about what is normal and what is not. Agreement about virtual risks is much more elusive. Participants in debates about such risks frequently question their opponents’ grip on reality and denounce those who disagree with them as “mad”. With such risks filters are all; the perception of virtual risk comes uncomfortably close to hallucination - defined as “perception in the absence of external stimuli”. The purpose of the drugs prescribed for people with personality disorders is to help them see the world as other, “normal”, people see it – to give them more insight. What is urgently needed for all participants in debates about risk is the intellectual equivalent of drugs and cognitive therapy that heighten insight. The Hierarchist would appear to be in need of treatment combining the lot. As governor of Bedlam his first priority is to keep order – a job best done empathetically. Risk is always with us and we will never reach complete agreement about how to manage it. There is no single, optimal, right way to do it - although there are ways that are clearly unsuccessful from all perspectives. The Government’s handling of BSE and its proposed reforms to the Mental Health Act are two prominent examples. At the root of such failures lie mistrust and paranoia, and the inability to agree about which phenomenon one is dealing with is part of the problem. The concealment of information at a crucial stage in the development of the BSE crisis was justified by a mistrustful (paranoid?) government that feared that the wider public could not be relied upon to react to the information responsibly. The wider public reciprocated this mistrust and the Government became incapable of reassuring it about anything. Whenever it insisted something was safe fatalists and egalitarians assumed that it must be covering up something dreadful. And the individualists who were still cheerfully eating (now cheaper) meat accused the environmentalists of scare mongering on the back of the Government’s ineptitude. With its proposed reforms to the Mental Health Act the Government has forged a mistrustful opposition alliance between individualists (antagonised by the threat to civil liberties) and egalitarians (who resent its stigmatising of a vulnerable part of the population). Debates about risk are debates about the future and the extent to which it can be shaped by human intervention. What would we like that shape to be? How can we achieve it? Such debates are interminable. But the harder all those involved strive to ascend the insight axis, the more civilised and constructive they are likely to be. Figure 8 illustrates this objective. How it might be achieved I know not. Perhaps the psychopharmacologists could devise something to put in the water? Figure 8 The insightful fatalist
The insightful individualist
The insightful hierarchist
The insightful egalitarian
Department of Health. Metnal Health Bill: consultation document. CM 5538 - III. 6-25-2002. Ref Type: Unenacted Bill/Resolution Home Office and Department of Health 1999, Managing Dangerous People with Severe Personality Disorder: proposals for policy development. Home Office and Department of Health. Reforming the Mental Health Act: Part II High Risk Patients. 2002. Ref Type: Unenacted Bill/Resolution Marris, C., Langford, I., & O'Riordan, T. 1996, Integrating sociological and psychological approaches to public perceptions of environmental risks: detailed results from a questionnaire survey, Centre for Social and Economic Research on the Global Environment, University of East Anglia, CSERGE Working Paper GEC 96-07. Ridley, M. 1997, The Origins of Virtue Penguin, London.


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