University of Gothenburg
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Henrik Anckarsäter

PROFESSOR/ CHIEF PHYSICIAN

Department of Psychiatry and
Neurochemistry
Mail
henrik.anckarsater@gu.se
Visiting address
Celam Rågården, Rågårdsvägen 5
42457 Gunnilse
Postal address
SU Östra sjukhuset Rågården Hus 1
41685 Göteborg

About Henrik Anckarsäter

Research Group
CELAM - Centre for Ethics, Law and Mental Health

Henrik Anckarsäter
Professor/senior physician in forensic psychiatry, Sahlgrenska Academy

Research

I became involved with research in addition to my work as a physician at the Department of Forensic Psychiatry in Gothenburg in 1995; Anders Forsman was my supervisor. At the time I was interested in the relationship between personality and the relatively new diagnoses of Asperger’s syndrome and ADHD. Anders stimulated my interest in identifying neurobiological vulnerability factors in people who had committed violent and sexual crimes. In 2002, I defended my thesis ‘Neuropsychiatric background factors to violent crime’ based on the Gothenburg Forensic Neuropsychiatry project (GFN), which has later yielded another two doctoreal theses. At the time, we collaborated with Robert Cloninger in St. Louis, USA, and with Christopher Gillberg, Maria Råstam and the group at the Child Neuropsychiatry Clinic in Gothenburg. I had the opportunity to participate in several international projects on the genetic effects underlying autism spectrum disorders, ADHD and the development of antisocial personality disorder and criminality with researchers such as Thomas Bourgeron in Paris, and was Principal Investigator together with Paul Lichtenstein in the base-line (9/12 years of age) Child and Adolescent Twin Study in Sweden (CATSS), which today is ongoing, followed prospectively into adulthood and has grown to be the world's largest twin study in child- and adolescent psychiatry. To anchor the development of forensic psychiatric knowledge in philosophy, ethics and law, we started the Philosophical Investigations in Forensic Psychiatry project (FILUR) along with Helge Malmgren and his colleagues at the Department of Philosophy in Gothenburg, which later formed the basis for the Centre of Ethics, Law and Mental Health (CELAM).

Following research and clinical work in Malmö/Lund and with Marion Leboyer at Université Paris XII in Créteil outside Paris, France, I returned to forensic psychiatry in Gothenburg in 2008, at the same time that I continued my guest appointment at Lund University. Our southwest Swedish research network developed into the Centre for Ethics, Law and Mental Health (CELAM). Fifteen doctoral candidates have defended their theses since 2009, and most of them have remained in research on their own grants. I have also hosted eight postdoctoral researchers, who have successfully continued to do research after their stints here. Today we are a strong interdisciplinary research group with many dedicated students.

For those who wish to view details about my work, my CV is available. In summary, I have published more than 150 original articles, over 30 review articles, book chapters and popular science articles. I have also supervised four PhD students who defended their theses and co-supervised others, worked with the International Academy of Law and Mental Health (IALMH, www.ialmh.org) to organize several major forensic psychiatric conferences (New York 2009, Berlin 2011, Amsterdam 2013), and edited two books along with Susanna Radovic and Thomas Nilsson. My greatest failure in research has been a ten-year project to write a monograph on why some people develop aggressive antisocial personality disorder and how to help them. Despite countless hours of reading and writing, I finally had to give up the idea of providing a comprehensive picture of this elusive question.

Clinical experience

In my clinical practice, I have mainly encountered adolescents and young adults with neuropsychiatric disorders and early personality problems, antisocial aggression and social marginalization, including within the National Board of Institutional Care (SiS) youth services for adolescents with psychosocial problems, at residential institutions, correctional treatment centres, psychiatric and forensic psychiatric clinics where I worked, or in private practice. I have also seen patients in London and Paris in connection with research periods there.

Teaching

I currently supervise and mentor postdoctoreal researchers. Previously I also taught medical students in Gothenburg and Malmö/Lund, and supervised PhD candidates, trained police in Stockholm and Växjö, and participated in a large number of in-house education programs. I have also been involved in developing an online course in forensic psychiatry for resident physicians and participated in training and supervision for this group.

Research

My research largely addresses the importance of neuropsychiatric problems on our ability to take responsibility for how we act, how we relate to others and to something or someone to give our lives meaning (our ‘character’). Deficits in the development of character is a common feature for all types of mental health problems, dysfunction and subjective mental suffering, and therefore a core target in psychoeducative and other forms of treatment. It is also a key feature behind aggressive antisocial behavior / personality disorder.

Today, we know that risk and protective factors can be found in our genes, in brain development and in the biochemical/physiological processes that interact with our mental processes. Research has established probabilities resulting from many different factors, rather than causation in the classic (mechanistic) sense. Life is thus unfair in the sense that we must contend with different predispositions--and of course relate to different environments. Some of us find it easier to mature as individuals than others, as well as refraining from violence.

In addition, habits and learned patterns further restrict our freedom, and our knowledge about the consequences of our actions is incomplete. Therefore it is important that we as health care professionals meet people without preconceived notions about what they can and cannot be held accountable for. The role of the doctor is to restore health and thus the pre-conditions for accountability.

However, this does not mean that science has excluded that thoughts or intentions may affect the body and physical events in the brain. Patients who believe they are receiving treatment for Parkinson’s disease show an increase in dopamine release in the brain, even if no treatment is given. The world is changed by ideas. We all know that willpower is essential to cope with challenges, that thoughts can provide courage when faced with fear, that love must be given freely and that we expect to be held responsible for the way we act, vote and conduct businesses.

The interplay of brain, senses and soul that creates a person remains a mystery that science has been unable to explain. Yet we have reason to believe that these are aspects of the same phenomenon (‘neutral monism’).

But these tenets have not been, and are not, consistent with the world-view of forensic psychiatry. Instead, the specialty builds on the assumption that humans are materially motivated according to the laws of nature. Therefore, forensic psychiatry has either advocated for criminal law legislation devoid of the metaphysical (of concepts such as competence, responsibility and punishment as a way to atone for the guilt of a crime), with protection of society and treatment as the sole objectives, or for a compatibilist model in which the person is held accountable, even if it is believed that he or she was unable to have acted otherwise.

Sweden went further in this direction than any other country with the 1965 introduction of the Criminal Code, which replaced the old Penal Code with a series of ‘sanctions’ including various types of ‘care’ (prison, forensic psychiatric care, probation, juvenile care, etc.). Today everyone seems to agree that this system has not functioned as intended, and that it should be replaced.

I believe that we would be well advised, prior to the upcoming revision of the Criminal Code, to exercise restraint in ‘translating’ psychiatric knowledge into law, since these two fields have different points of departure: one wants to eliminate the causes of ill health, and the other wants to hold people accountable for bad actions committed intentionally.
What we as doctors can comment on with certainty in courts of law is the lack of alertness, orientation and clarity (disturbances in the thought processes). Such impairments may be due to mental or physical illness and may have ‘destroyed’ (the wording used in the legislation on international crimes) the ability to act responsibly. In such cases (for example, in severe confusion or dementia), just about anyone can understand that this has happened and no intent in a legal sense has existed.

However, when doctors assess thought content, assessments become much more uncertain (as we have seen in some court cases garnering media attention, such as that of the Norwegian terrorist Anders Behring Breivik).

If future penal legislation in Sweden and elsewhere assumes that responsibility is the norm and limits the opportunity to obtain special penal treatment for clear cases in which the ability to act responsibly has been destroyed more people with mental illnesses will be sent to prison. This scenario would in turn result in higher demands for flexibility in the implementation of sanctions, which must include care, (re)habilition and opportunities to serve the final phase of the sentence in open forms.

The challenge is twofold: to accept the need for a well-functioning rule of law while offering all proper care as needed. A person may be psychologically disturbed, in need of care and accountable for their actions, all at the same time. It is even the norm in the justice system, where most prison inmates require various health interventions. As psychiatrists, our mission is to provide care, develop knowledge and propose changes to make justice more therapeutic (‘therapeutic jurisprudence’), but not to take over responsibility from lawyers or to naively translate our knowledge into their field of expertise.

When we conduct research about people, we work in different epistemological frameworks, which have different premises to respond to different questions. For example, brain imaging studies can show regional brain activity while lifting an arm, but cannot answer the question of whether lifting the arm was a good idea or clarify the intentions behind the act.

In this truly cross-sectional field we must work to rigorously interpret scientific knowledge within strictly defined epistemological frameworks. Forensic psychiatry has often extrapolated results from one method of scientific inquiry to answer questions that address entirely different aspects of human behaviour (‘Charlie didn’t break the window, it was his ADHD that did it’ or ‘if he had a brain tumour, you wouldn’t think he was to blame’ even though most people with ADHD or brain tumours do not break windows or commit crimes).

The relationship between mental disorders and physical aggression is not simple to untangle. The majority of all violent crime in society is committed by a small group (1% of the population), almost always men who started to behave violently early in life and then went on to do so throughout their life-spans. Generally they have also had problems with hyperactivity, impulsivity and/or abuse. This group has been shown to be overrepresented in every diagnosis group within psychiatry, while few, if any, conclusions on the direction of causation are possible.

People with psychoses are at slightly greater risk of committing crimes, but this increased risk is carried by a sub-group of people who also had early behavioural problems before the onset of psychosis and subsequentley progressed to abuse and crime. In contrast, genuine ‘acts of madness’ among previously non-violent individuals are extremely rare and essentially impossible to predict, since they tend to occur either early in the course of disease (when they can be bizarre and directed against strangers) or late, when they are most commonly directed at family members without any specific warning signs.

A central task of forensic psychiatry has been to carry out risk assessments of individuals who may be prone to violent acts. Recent research has shown that such assessments are based entirely on previous criminal behaviour combined with (young) age at onset, (the presence of) substance abuse and (male) gender. It has not been possible to show that any specific psychiatric factors increase the accuracy of predictions above what can be achieved by data that anyone can record or quantify. As we have no evidence-based additional certainty to add, I think we as health care personnel must refrain from speculating about long-term risk for violent crimes or behaviour.

Instead, our mission is to help people who have, or are about to develop, patterns of antisocial aggression and thereby try to prevent violent acts in a here-and-now perspective. The most important step toward this end is to develop methods of breaking the pattern of early violent behaviour in children and adolescents, while helping them to avoid substance abuse and marginalization. To achieve this goal, schools must offer an environment free of violence, where the law is upheld and where it is just as obvious that children are not allowed to physically assault one another as it is that adults are not allowed to abuse them. For those who wish to learn to use violence, options include sports and activities that respect the societal monopoly on violence. If specially trained school police officers are necessary to secure a good environment for children and to ensure that fighting and threats of violence do not become a ‘winning strategy’, then this is a discussion that must be had.

In recent years a new and rather unexpected problem has arisen at the juncture between psychiatry and law. The results from various studies suggest that current psychiatric diagnoses may not be supported by scientific data. Consensus between different assessments is much less than we thought. The same risk factors and biomarkers seem to give rise to completely different problem complexes in different people. Almost no patients have a ‘pure’ diagnosis, but many diagnoses are made on a case-by-case basis and regularly change with each new care provider. Medications often affect many different problems and, with few exceptions, are not specific to any particular diagnosis. In 2013 there was even talk in the journal Nature that addressed psychiatric theory, comparing it to a broken airplane requiring ‘in-flight’ repair. As this has consequences for all diagnosis-based research, I think we must take these concerns very seriously with a humble approach to new scientific findings if we are to maintain credibility. A possible way forward would be to focus on mental functioning and (freedom of) suffering as outcome measure rather than categorical diagnoses, and then empirically identify susceptibilities and protective factors.

To sum up, I believe that forensic psychiatry should focus on treatment of those individuals who actually search treatment, starting by clearly defining problems instead of using categorised diagnoses: assess patterns of aggressive antisocial behaviour, psychosocial dysfunction and/or suffering, and then without bias address scientifically identified biological, cognitive, affective, behavioural and social risk and protective factors. Aggressive antisocial behaviour has been shown to constitute a clinically meaningful behavioural phenotype, a rather stable and recognizable problem complex for which neuroscientific studies and therapeutic research hold promise.

First published on the CELAM web-site in March 2014, slightly revised December 2017 and March 2018.