Sunday 19 August 2007


I'm a doctor. The professionals I work with with most are nurses. We're part of the local health community, improving health through helping patients and supporting GP colleagues.

We try to help patients a lot, seeing every new referral within days, sorting out usually at least half a dozen (and up to 15, recently) helpful interventions to improve things with them. We invariably work with them rather than passively doing things to them. Last year I had a ward for several months with no inpatients at all . . . if we can help folk cope in the community (even with significant risk present) then we do.

Last year I managed 11 months without any use of the Mental Health Act at all, but in December had to recommend admission under a section of the Mental Health Act 1983 (MHA 1983) for one individual.

Overall we admit seldom and compulsory admission is pretty rare. Patients trust us, and rightly so.

Zarathustra has provoked discussion about assessment for treatment. Rather than derailing his thread with rambling comments I wanted really to take it away from the discussion on legislation and Code of Practice and towards implications arising from a shift in culture.

At the moment patients who have mental health problems and present criminal risk (of harming others) have their health needs treated. This is done mostly in psychiatric hospitals (and sometimes in the community) and what can't be treated isn't treated. Obviously. Because it can't be treated. When such an individual then makes threats to harm others they're then managed through the Criminal Justice route, being locked up in prison if necessary.

This makes sense to me.

If you're being bad 'cause you're ill, society believes we should treat the illness, get the person well and all is good.

If you're being bad 'cause you're choosing to be bad (and you're not ill), you go to the courts.

If you're being bad and it's all a bit of as muddle then section 35 of the MHA 1983 means that instead of remanding the person in prison they're admitted to a psychiatric hospital for preparation of reports for the court (initially for 28 days then renewed by the court for up to 12 weeks).

Courts can then make sensible decisions as to how much a person's actions are their own elective choices and how much arises through mental illness.

At present, even with mental illness being present, most folk go to prison not hospital. If you've a violently explosive personality and hit people a lot, you've tried to "get help" but that's just how you are, what can a hospital do for you? It can contain you. Keep you locked up so you don't hit people. It's not improving you, it's not helping you in any meaningful way, it's simply reducing risk to people at large through containing you. Since this role is served better by prisons, unsurprisingly most violent individuals with F60.2 Dissocial Personality Disorder (also called psychopathic) who can't be improved/cured are in prison. They're contained.

There's a fashionable idea in the corridors of power that these folk should be in hospitals. In fact, anyone who's a risk to the public and is mentally ill should be locked up in psychiatric hospitals. Given we can't cure these people and we've no way of evidencing a reduction in risk at some point in the future, they've no easy way of getting out. Ever.

Do we want psychiatric units which currently serve vulnerable, distressed individuals who are unwell to be awash with folk who are violent and essentially untreatable? If patients see mental health work not as collaborative partnership but as a scary unsafe world with folk locking people away for ever "just in case" I'd see the essence of care being thoroughly undermined and the positive culture (that we're finally coming to experience) will be lost.

Health care should do the caring for the peoples' health. Prisons and specialist forensic units should do containment. I can't see how else folk with mental health problems would ever be tempted to enthusiastically seek out and engage with mental health services.


Spirit of 1976 said...

Hi Shrink.

Thanks for your thoughts on this subject.

Just out of curiosity, how many extra people do you think will be detained as a result of the changes in definition? This is something I've been pondering a lot lately.

The Shrink said...

How many will be detained will largely be determined by he stubbornness of psychiatrists vs the behemoth of Government directives.

Most psychiatrists I know have no interest in this at all so won't be keen to incarcerate someone who's not yet done the crime, on the offchance that they might, then have to look after them as an inpatient forever.

On the other hand I could promptly fill my ward with people who aren't actutely unwell, so may make for a peaceful life ;-)

I think that psychiatrists will probably continue to use common sense rather than the letter of the law and resist change.

Just the way the NICE guidelines changed who could have antidementia medication (so now everyone has indeed got moderate dementia so can have the drugs . . . and the fact they score as mild is simply 'cause they've luckily got a few well preserved islands of ability ;-) ) psychiatrists will largely continue to do what they believe is right, despite changes being enforced around us.