A mad approach to mental illness

In its second term, the New Labour government plans to make mental health a big issue – but why is it more concerned with ‘risk and safety’ than treatment and resources?

In December 2000, the government published its white paper, Reforming the Mental Health Act 1983 – with a heavy focus on keeping the public safe. While the paper promised to address the lack of resources in mental healthcare, the foreword by then home secretary Jack Straw was preoccupied with safety. According to Straw, the present legislation has failed to protect the public, patients or staff, and has undermined public confidence in care in the community (1).

To address this ‘failure to protect’, the paper proposes legislation to allow the enforced treatment of the mentally disordered without their needing to be admitted to hospital, otherwise known as a community treatment order (CTO). And the new legislation will allow the indefinite detention of those deemed to have a personality disorder and considered a danger to the public – even if they have not committed a crime. Under the 1983 Mental Health Act enforced treatment can only be given if somebody is a detained patient, and prolonged detention must be on the grounds that the mental disorder is ‘treatable’.

In part, the government is responding to recent high-profile inquiries into homicides committed by people with a psychiatric diagnosis – which often conclude that poor communication and follow-up by mental health services contributed to the tragic incidents. But how strong is the link between mental illness and violent crime?

The UK Zito Trust, set up by Jayne Zito after her husband was killed by a schizophrenia sufferer in 1992, claims that, in Britain, approximately two people per month are killed by ex-psychiatric patients – half of whom had stopped taking their prescribed medication (2). These claims gained widespread media attention – something of a tautology, considering that the Zito Trust largely relied on press clippings for its findings. But the impact of mental disorders on violent behaviour is complex, and just looking at press reports is not the best way to understand the complexities.

Somebody may have had a psychiatric history and may have committed a violent act, but this doesn’t necessarily mean that the former led to the latter. Somebody may suffer from psychosis and may commit an act of violence, but if the psychosis played no part in the act that is not the same as an actively psychotic person attacking somebody. Such causal explanations are too simplistic.

One comprehensive review of the relationship between mental disorder and violence argued that methodological problems had clouded the debate. Published in the Journal of Health and Social Behaviour, the review questioned research that claimed to show an association between mental disorder and violence, pointing out that the patients in the studies were not typical of the majority of the mentally disordered, and there was no comparison group. The review concluded that ‘the contribution to violence of major mental illness, current psychotic symptoms, or threat/control override symptoms is only modest’ (3).

In relative terms, a diagnosis of major mental illness is less a predictor of violence than being young, male, substance-abusing or substance-dependent. In terms of homicides, severe mental illness was found to be less of a factor than personality disorder or drug and alcohol abuse (4).

The case for a community treatment order on the grounds of public safety also fails close inspection. The medication given under a CTO would be for severe mental illness, not for alcohol or drug misuse – and so would be unlikely to have much impact on public safety. This is supported by two recent studies – one found that non-compliance with medication was over-emphasised in cases of homicides committed by ex-patients (5); while the other, an extensive national inquiry commissioned by the Department of Health (DoH), could only surmise that compulsory CTOs may prevent three homicides per year (6).

Even if we accept the DoH’s claim that three homicides may be prevented, the obvious question is: which three? How many people will have to undergo enforced community treatment to cover all possible eventualities? The emphasis on risk-avoidance in mental health looks set to push through further coercive legislation against those diagnosed as mentally ill. The British state will for the first time have the right to force people in the community to take drugs against their will.

Not surprisingly, many mental health groups have reacted angrily to the civil liberties implications contained in the government’s white paper. Some mental health professionals, acutely aware of psychiatry’s dilemma between care and control, also feel that the white paper is a step too far towards the latter. Mad Pride, a group set up by ex-psychiatric patients specifically to oppose CTOs, has organised petitions and pickets to protest against the authoritarian nature of the proposed legislation.

Despite the name, Mad Pride talks a lot of sense, highlighting issues such as the severe side-effects psychiatric drugs can cause, the lack of evidence to warrant CTOs, and the way groups like the Zito Trust and the media exaggerate the problems of mental illness and stigmatise the mentally ill. All of which is far less mad than what the government is proposing.

Ken McLaughlin is senior lecturer in applied community studies at Manchester Metropolitan University.

Read on:

Is mental illness just ‘different’?, by Fenno Outen

Mental illness: all in our minds?, by Fenno Outen

(1) Reforming the Mental Health Act 1983, Department of Health, 2000

(2) ZT Monitor: The Journal of the Zito Trust, Issue 2, October 1997

(3) ‘The social context of mental illness and violence’, Hiday, Journal of Health and Social Behaviour, Vol 36, pp122-137

(4) Safety First: Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Department of Health, 2001

(5) Key Issues from Homicide Inquiries, C Parker and A McCulloch, MIND publications, London, 1999

(6) Safety First: Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Department of Health, 2001