Sir: Chiswick (Psychiatric Bulletin, August 2001, 25, 282-283) has captured the essence of the proposed Mental Health Act reforms with regard to dangerous and severe personality disorder (DSPD).

The existing Mental Health Act always gave clinicians the power to detain patients with psychopathic disorder in a hospital for treatment if the patient was thought to present risks to others. Treatment of patients with psychopathic disorder is stressful because of the difficulties in treating them, the resources they take up, the strong countertransference reactions these patients evoke and the staff burnout that they cause. Therefore, understandably, clinicians resort to a narrow interpretation of the ‘treatability test’.

In the proposed reforms, the emphasis is on the fact that this group of patients needs treatment and that the interpretation of the treatability test needs to be a broad one.

The main arguments put forward by clinicians against the proposals are that (a) patients who are not treatable should not be detained and (b) it is unethical to detain patients for public protection alone.

Taking the first argument about treatability of psychopathy, there is a lot of evidence in the literature that psychopathy can be a difficult condition to treat, but not entirely untreatable.

As to whether it is unethical to detain patients when they pose a risk to others, it can be argued that because of the high probability of their offending, patients with DSPD run a high risk of being imprisoned and being the victims of retaliation by others and therefore detention in hospital prevents offending behaviour and protects them from the consequences thereof.

If we as clinicians refuse to treat people who are clearly unwell and distressed, we would be failing in our duty of care and pushing these vulnerable patients into the criminal justice system.

Since it seems inevitable that the proposals will become law, we should be fighting for more resources to be able to deliver the services this group of patients need.