Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Psychiatrists as agents of public protection
- Prabhat K Mahapatra (21 February 2003)
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D(r)aft Mental Health Bill
- Chris Manning (22 February 2003)
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Psychiatrists and preventative detention
- Stuart M White (24 February 2003)
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Psychopathy and free will
- Arthur Rifkin, MD, Glen Oaks NY 11004, USA (24 February 2003)
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He who pays the Piper
- Sameer P. Sarkar, MD (25 February 2003)
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No Mention of Child Abuse
- Mark S. Kern (26 February 2003)
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Should Psychiatrists potect the public?
- S.P. Sashidharan (18 March 2003)
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Prabhat K Mahapatra, Consultant Psychiatrist Care Principles, Barham, Canterbury CT4 6PW
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Editor- Coid and Maden (1) rightly point out that the proposed Mental Health Act legislation will turn psychiatrists into agents of public protection. Whereas, GMC guidance expects doctors to act in the best interests of the patient, under the new Act, doctors will be expected to detain patients even if it may not be in tne patient's best interest. With the low sensitivity and specificity of current risk assessment tools, huge numbers of innocent patients will need to be unnecessarily detained in order to prevent even one homicide. Recruitment and retention in psychiatry is already a problem and is likely to worsen if the Bill is passed in the Parliament(2). Morale among psychiatrists is low partly because of the inadequate resources available. Making psychiatrists responsible for offenders without providing the considerable resources needed is going to be a recipe for disaster. There are concerns that resources will be significantly diverted from community care to secure facilities and from the NHS to the independent sector once the new Act comes into force. Under the new Act, hospital managers and nearest relatives and in some cases even the RMO would lose their power to discharge patients. The Mental Health Review Tribunals have come under fire for being unable to run the tribunal system smoothly. Under the new Act, the workload of tribunals would increase enormously without a concomitant increase in human and finacial resources. The approved social worker servs an important function as an independent check and balance preventing psychiatrists from abusing their position of power under the current Act. There are concerns that loss of the role of ASW in the proposed Act will lead to detention under the Mental Health Act being seen as an act of collusion between doctors and the approved mental health professional who is likely to be a community nurse who is not independent of the doctors and the NHS trust. The proposed Act has a few positive aspects to it. The new Act will close the Bournewood gap for patients with incapacity. The new Act will also ensure that patients have independent advocates (as to whether trusts will have any money left to run an advocacy scheme is another matter). The new Act will make it easier to treat non compliant patients in the community with the introduction of community orders. It remains to be seen whether the government pushes the Bill through in spite of the unanimous opposition to the Bill from all stakeholders. The absence of the Bill being mentioned in the Queen's speech in November last year has raised hopes that the Bill may be shelved after all! However, the Health Secretary has promised to see that the Bill is passed during the tenure of the current Parliament. 1.Coid J, Maden T. Should psychiatrists protect the public? BMJ 2003;326:406-407 ( 22 February ) 2.Spencer M, Gregoire A. Specialist registrars' views on the proposed reform of the Mental Health Act (1983): Potential impact on recruitment and retention of consultant psychiatrists. Psychiatr. Bull; 26: 374 - 377 (Oct 2002) Competing interests: None declared |
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Chris Manning, CE PriMHEHon Vice-President of Depression Alliance. Twickenham TW1 4JA
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Dear Sir, Silence is more than the absence of noise and psychiatry is much more than the management of those with severe and enduring mental illness (another phrase variously interpreted that has also, in my opinion, taken the profession down a blind alley in terms of diagnostic confusion and subsequent service commissioning), and within that, the very small remit of psychopathy. To reduce an already stigmatised profession down to the lowest common denominator of becoming societal policeman with crystal balls will effectively seal its fate. Lack of case mix and engagement with a wide range of community issues that are relevant to the practice of this specialism are burning many out. The principles of early intervention, "assertive outreach" (better might be "supportive and upstream care in the community"?)and home treatment are generic highest common factors for all areas of clinical practice. Further, localities differ in their needs for such services, so rolling the dough over the nation without relevance to local needs is also crude. The Draft Mental Health Bill must NOT be allowed to go through parliament as it stands. Thus far, it has already done more to unite mental health third sector organisations and professional bodies than any previous issue and we intend to watch this issue like hawks and unite even further to lobby against and block this intended legislation. This article illustrates precisely what could be developed as a solution and perhaps those of us in the sector with an interest now need to focus our attentions on the risk-averse Home Office? All those who feel strongly about this issue should contact Paul Farmer, Chair of the Mental Health Alliance at the charity Rethink. Yours Faithfully, Dr Chris Manning Competing interests: None declared |
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Stuart M White, Lecturer in Anaesthesia St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH
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Dear Editor, Professors Coid and Madden are right to suggest that the ultimate societal responsibility for persons with dangerous severe personality disorder (DSPD), and similar, should not reside with psychiatrists [1]. In addition, they may be right to assume that ‘most psychiatrists probably support recent criminal legislation designed to improve public protection by introducing tighter controls on high risk offenders’. However, it should be emphasised that what is being proposed by the government in Reforming the Mental Health Act, involves in part a potential for the indefinite incarceration of people based on the spurious psychiatric diagnosis of severe personality disorder before such individuals have committed any crime – so called ‘preventative detention’. This is most definitely not supported by the psychiatry profession [2]. The proposed legislation may be further criticised on a number of accounts [3]. Diagnostic difficulties mean that some of those with DSPD will be diagnosed as normal. More importantly, the potential for misdiagnosis is high (the diagnosis appears to be only 60% accurate). The ramifications of misdiagnosis, namely wrongful imprisonment and the consequences of inappropriate psychiatric labelling, are patently severe. Questions remain - how dangerous does a person have to be (violence is not an inevitable aspect of DSPD [4])? What do we do about children diagnosed with DSPD? The treatability of DSPD is also a contentious issue [5]: if the condition is untreatable, can patients be held under the Mental Health Act? If it is treatable, is new legislation really necessary? Moreover, why stop at DSPD? In terms of the social control of criminality, one can imagine a situation where other criminals, or potential law breakers, may be detained indefinitely on the basis of controversial ‘personality disordered’ diagnoses - the pyromaniac arsonist, the ‘velocimaniac’ driver - both are effectively untreatable conditions (being an inherent part of the character) and all dangerous, to both the public and themselves. Worryingly, preventative detention on the basis of personality disorder could then relatively simply be applied to non-criminals, with the diagnostic criteria expanded to include, for example, political affiliation or sexual orientation; Orwell’s concept of the ‘thought crime’ suddenly becomes very real. Risk reduction amongst offenders with DSPD is laudable. However, doctors, particularly psychiatrists, must continue to resist the Government’s attempts to use preventative detention as a method of social control. References 1. Coid J, Maden T. Should psychiatrists protect the public? BMJ 2003; 326: 406-407 2. Royal College of Psychiatrists. www.rcpsych.ac.uk/press/preleases/pr/pr_152.htm 3. White SM. Preventative detention must be resisted by the medical profession. J Med Ethics 2002; 28: 95-8 4. Mullen PE. Dangerous people with severe personality disorder. BMJ 1999; 319:1146-1147 5. Cope R. A survey of forensic psychiatrists' views on psychopathic disorder. J For Psych 1993; 4: 215-236 Competing interests: None declared |
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Arthur Rifkin, MD, Attending Psychiatrist The Zucker Hillside Hospital, Glen Oaks NY 11004, USA
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Aren't we trying to square the circle in using psychiatric diagnoses to determine society's response to criminal behavior? Psychiatry, a medical science, assumes the absence of free will. We would never think it satisfactory to explain the etiology of a mental disorder as free choice. That implies a causeless cause beyond the reach of science. The criminal justice system depends on free will. Only a person who could have acted differently should be punished. Trying to combine psychiatry and the criminal justice system inevitably causes serious problems because of their different assumptions. What to do? I foresee no clear way out of this conflict except to contimue to bumble through. The real answer would acknowledge the illusion of free will and alter the criminal justice system to emphasize rehabilitation and not retribution. Then we could use psychiatry to provide what information it may have to improve rehabilitation. Competing interests: None declared |
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Sameer P. Sarkar, MD, Consultant Forensic Psychiatrist Broadmorr Hospital, Berks, RG45 7EG
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Dear Editor: Professors Coid and Maden (1)do not seem to like the disquiet that is currently among the vast majority of psychiatrists. I could be wrong in my reading but the careful choice of the phrase 'the rhetoric should cool now' makes me wonder if I am indeed right. They cite clash of philosophies (between Dept of Health and Home Office) to be a root cause but I suspect this difference is reflective of the clash of differing values between two sets of professions. Or indeed a clash between Justice and Welfare. I agree that psychiatrists can not 'have their cake and eat it too' anymore than any of us. But just because psychiatry has benefitted from the Welfare principle of the existing criminal justice system, it does not mean that it has now lost the moral right to object to further transgressions. And this is precisely why, even if we are percieved by the Government and its lackeys as an irritant, Psychiatrists should keep on protesting, in a united voice. What psychiatry, an essentially medical discipline has got to do with risk reduction and reducing recidivism remains firmly beyond me, especially in cases where there can not be a clear demonstration of a functional link between the disorder and the behavior. If redefining our professional role or identity requires that we will do what people want us to do and are willing to pay for, we might as well call ourselves mercineries, or better still 'Psy-police'. In that case I would like to know when and how did we get the public mandate to protect the public. In the absence of that clear mandate, are we not running the risk of harming our patients if we agree that our patients still percieve us as someone who will do what is best for them or at least not harm them. For them to believe otherwise will need a major paradigm shift, and perhaps something more visible, like a Uniform. In absence of clearly given warning that the interview will be used for risk assessment with its accompanying consequences, and obtaining clear consent from the evaluee, perhaps the only good we are doing to the patient is that maybe we are preventing him from doing something bad, which will then benefit him by NOT having to suffer the consequence of the bad act. But because that is not an argument we apply to ourselves, this discrimination seems to be based on prejudice and stigma, which the Royal College has struggled hard to eradicate. Psychiatrists should, and indeed must continue to protest against further infringments on our liberty. Because if we don't, there will be no one to protest when my time comes. But of course we could have a set of rules for us and a different set for 'them' but then our fundamental protections become matter of soverign grace rather than clear entitlements. Reference: 1) Coid J and Maden A:Should psychiatrists protect the public? BMJ 2003;326:406-407 Competing interests: None declared |
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Mark S. Kern, none 80302
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I saw no mention of child abuse in either the report or the responses. I doubt there are more than very few who have used the services of psychiatrists, that are not adult survivors of child abuse. No doubt, most of those in prison, and most of those diagnosed as mentally ill, are adult survivors of child abuse. "The debate's moral focus has largely neglected two pragmatic questions. Firstly, is the health service equipped to take the lead in public protection? Secondly, can the philosophy underpinning strategy of the Department of Health for mental health be reconciled to the public protection agenda of the Home Office?" It is immoral to label survivors of child abuse 'mentally ill'. They were dealt a paradigm in life that fits poorly into society, and that is their plight. Some choose crime, others live with disability support, and others fit in as best as they can, albeit often poorly. If someone commits a crime, then let them face the penalties of the crime, regardless of their standing with the psychiatric profession. Since when has the psychiatric profession improved crime statistics. I believe this answers both of the above issues being debated. One thing about survivors of child abuse. All but few of them are apt to know they were abused, as the most severe abuse took place when they were infants. The abuse may have been caused by their parents, an older sibling, or just about anybody . . . that came into contact with them when they were infants. They may have had really decent parents, who welcomed them into the world, but encountered one person when they were most vulnerable . . . that damaged them for life. A person's brain is enormously developed during their 1st year. People don't remember their first year in life, but they live with it for the rest of their life. Competing interests: None declared |
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S.P. Sashidharan, Medical Director Northern Birmingham Mental Health Trust, 71 Fentham Road, Birmingham b23 6AL
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EDITOR-The article by Coid and Maden1 is welcome. They make explicit one of the most important fault lines within contemporary mental health service planning and policy, the seemingly irreconcilable conflict between the preoccupation with managing ‘risk’ and the demand for health care interventions based on health care needs. This fundamental contradiction between care and custody, which has never been resolved satisfactorily at any time in the history of modern psychiatry, is once again made visible by the current choice facing mental health services, the clinical priorities around responding to private distress threatened by A political requirement to manage public disorder. Currently, these two themes are conflated in mental health policy and service delivery. Clearly this does not help, either in reduction or minimisation of risk or in providing people suffering from mental distress or illness with the care and treatment that they need. Much of what is going wrong with the current ‘modernisation’ programme within mental health2 could be traced to the failure to separate these two incompatible positions within policy and service development. The increasing preoccupation with ‘risk’, for example, evident in the requirements of the Care Programme Approach, within the proposed new legislation and the expansion of secure provisions, both in the NHS and in the independent sector3, is already beginning to corrupt clinical practice as well as undermining the values and principles associated with the National Service Framework. The investment plans within mental health are also skewed by the demands for more ‘secure’ services, resulting in less money being available to support much needed community services and for the implementation of the NHS Plan for mental health. It is gratifying to see that the authors, both forensic psychiatrists, agree that it is important to separate the two approaches, one based on ‘risk’ and the other primarily concerned with ‘care’, in the organisation and delivery of mental health services. The authors however do not take their arguments to their logical conclusion. As we consider yet another strategy to manage ‘high risk individuals’ or those with the dubious diagnosis of psychopathic disorder, this might be an appropriate time to re-examine the troubled relationship between forensic psychiatry and the rest of mental health services. The former is primarily premised on the assumption that there are particular skills, expertise or techniques which forensic psychiatrists possess which, along with the technologies of control and legal prohibitions available to them would lead to risk minimisation in clearly delineated groups of patients. By and large, such assumptions remain untested and unproven. None the less, as the authors suggest there is a need for such services, primarily concerned with public order and social control to support the work of the criminal justice system. But, is it necessary or viable in the long term for this to be undertaken through the health services? Forensic psychiatry is chiefly concerned with public protection while much of the rest of mental health strives to prioritise individual rights and needs, in the context of health care delivery. Perhaps it is time to ensure that mental health services do not continue to be disabled by what Coid and Maden refer to as the ‘clash of ideologies’. To achieve this, however, it might be necessary to make all of forensic psychiatry a part of the criminal justice system, thus making explicit what is increasingly the norm in policy and practice. Finally, the authors’ comments about the model of community mental health care in North Birmingham are inaccurate and misleading. Their assertion that this model was found to be ‘deficient in risk assessment and both pubic safety and patient safety’ is attributed by the authors to a report of a clinical governance review by the Commission of Health Improvement4. The CHI report makes no such criticism. The report, in fact, makes it explicit that it was not meant to be an evaluation of the service model. The review ‘only looked at the clinical governance arrangements’ within the Trust. Furthermore the methodology used by the reviewers prevented CHI from coming to any conclusions about the overall impact of the services in relation to patient or public safety. In fact the review makes no mention of public safety at all. Coid and Maden should have taken the trouble to study the report before relying on it to assert their prejudices. Professor S.P.Sashidharan
1 Coid J, Maden T. Should psychiatrists protect the public? BMJ 2003; 326: 406-7 2 Priebe S, Turner T. Reinstitutionalisation in mental health care. BMJ 2003; 326:175-6 3. Poole R, Ryan T, Pearsall A.The NHS, the private sector, and the virtual asylum. BMJ 2002; 325: 349-50 4 Commission for Health Improvement. Report of a clinical governance review at Northern Birmingham Mental Health NHS Trust. London: CHI. July 2001 Competing interests: Medical Director, Northern Birmingham Mental Health Trust |
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