New bill offers control for mentally disordered offenders

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7086.1047 (Published 05 April 1997) Cite this as: BMJ 1997;314:1047
  1. D J Thompson, Consultant psychiatrista
  1. a Malham House Day Hospital, Leeds LS2 9LN

    Editor—In his recent editorial Derek Chiswick commented that clause 36 of the Crime (Sentences) Bill “runs contrary to modern concepts of psychiatric practice.”1 Central to this debate is the issue of responsibility, the extent to which a psychiatric patient can be held responsible for a criminal act. Policy in this area has followed the recommendations, in 1975, of the Butler committee: “Prosecution should be seen as a last resort,”2 which were subsequently reaffirmed by the Read review in 1992: “Wherever possible receive care and treatment from Health and Social Services rather than in the Criminal Justice System.”3 The bill is a major change from this position; it offers the court the opportunity to combine treatment and punishment and thus to consider the issue of a patient's individual responsibility for an offence.

    The change should be welcomed. The majority of high profile failures of community care have involved patients with a history of offending behaviour. They rarely face prosecution because of the current policy. I have looked after several patients who have assaulted members of the public, staff, and other patients, both in the community and in hospital. They have rarely, if ever, been prosecuted. This problem has increased in recent years with the development of community care and the widespread availability of psychoactive drugs. Community care offers new opportunities and freedoms for patients, but with it comes a responsibility for patients to cooperate and help in the management of their own illness. Current practice often seems to place psychiatric patients above the law, without risk of prosecution for a range of offences. In this context prosecution may have benefits beyond the immediate protection of the public. It offers the prospect of encouraging patients to comply with their treatment regimen, whether this is compliance with prescribed medication or avoidance of psychoactive drugs that might themselves trigger a relapse; it may also have some value in increasing patients' insight into the seriousness of their behaviour when ill, and it emphasises the responsibility of the patient to assist in cooperating with their own care and treatment.

    The opportunity should be seized to provide a legal framework that will underpin and strengthen the controls for managing mentally abnormal offenders in the community. This would include wider prosecution of offences, greater use of sentences such as “probation with treatment as a condition,” and a new section of the Mental Health Act 1983, such as a community treatment order which would build on the acknowledged success of restriction orders.4


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