Scare in the community

In the past two weeks there have been three major publications which appear to corroborate the view that the policy of care in the community is putting the public at risk from psychiatric patients. November saw the introduction of the Mental Health Bill 2006, the government’s latest attempt at mental health legislative reform (1). This came one day after an inquiry report into the death of Denis Finnegan, killed by John Barrett as he cycled through a central London park on his way to work (2). Two weeks later came the latest ‘five year report of the national confidential inquiry [NCI] into suicide and homicide by people with mental illness’, which claims that one person a week is killed by someone with a diagnosis of schizophrenia (3).

Predictably, the government has used the reports to justify the more controversial aspects of its Mental Health Bill. Health minister Rosie Winterton, stated that ‘we need to make sure that the care that we can provide in the community is reflected in modern legislation….there are patients who don’t continue to take medication…[and] at the moment we have no power to be able to say that we want people to take medication’. As the NCI report’s title, Avoidable Deaths suggests, the authors and the government believe that many of these deaths could have been prevented.

Under the present Mental Health Act 1983 patients can only be compelled to take medication against their will when they are detained under section in hospital. Once discharged they regain the right to refuse medical treatment that most of us take for granted, even if it is detrimental to our health. Given the often severe side-effects that anti-psychotic medication can have, many patients exercise this right and stop taking it. The Bill will remedy this by introducing a ‘Community Treatment Order’ and patients subject to it, once discharged, can be forced to take their medication.

The Bill also proposes to allow those with a personality disorder and who are considered dangerous to be detained indefinitely even if they have not committed an offence. At present such detention can only be justified if the patient will benefit from treatment, and many professionals believe that most of those with a personality disorder are untreatable. What many of us would regard as common sense – if we are to be kept in hospital against our will then at the very least we should expect some medical benefit – the government sees as an impediment to public safety. The Bill will allow such detention merely if treatment is ‘appropriate and available’. It need not be clinically effective (4).

Reading these reports and earlier inquiries into individual deaths, I certainly agree that practical steps to improve current practice can be made, and both make some useful points that need to be considered. However, they do not give weight to the government’s plans; on the contrary they not only show that there has been no increase in homicides, they also highlight the dangers of the proposals, and the distasteful way ministers use such tragedies for their own agenda. For example, linking the John Barrett case to a need for community treatment orders conveniently overlooks the fact that he was actually an in-patient at the time of the killing. He had absconded from the hospital grounds. Whilst noting many professional failures in this case, the chair of the inquiry team stated that, ‘the remedy for what went wrong in this case lies not in new laws or policy changes’ (5).

The NCI report investigated 249 cases of homicide (and 6,367 suicides) (6) by people diagnosed with a mental disorder between April 1999 and December 2003. This represents nine per cent of the total of all homicides in England and Wales during this period. The number of homicides by those diagnosed with schizophrenia was approximately 30 per year, representing five per cent of the total. There has been no increase from the previous NCI report in 2001, which followed a study in 1999 that found a three per cent annual decline in homicides by ex-patients (7). The relationship between mental illness and violence is a complex one, with factors such as drug and alcohol abuse further complicating the matter. In fact, drug or alcohol dependence alone is deemed to be a mental disorder and is therefore included in the NCI statistics. ‘Stranger homicides’, where perpetrator and victim did not know each other, are rare and have not risen. Family and friends are the most likely victims. In other words, the risk to the general public is negligible.

With the government planning to introduce fundamental changes to long standing safeguards for mental health patients, such as the right to refuse medical treatment in the community or to be detained indefinitely on the grounds that professionals think you’ll commit a crime at some future point, then it seems reasonable to think that the risk assessment procedures are robust and accurate. Well, not exactly. According to the NCI, 29 per cent of those who went on to kill were seen by mental health professionals in the week preceding the homicide, and not judged to pose any significant risk. At the final contact between patient and services immediate risk was judged to be low or absent in 88 per cent of cases. Long term risk was judged to be low or absent in 69 per cent of cases.

In addition, a significant percentage had had no prior contact with services. Of those diagnosed with schizophrenia, only half had current or recent contact with services, whilst one third had no previous contact. Of those deemed to suffer from personality disorder 55 per cent had no previous violent convictions and 43 per cent no previous contact with services.

Little wonder then that the report itself states: ‘We have no reliable way of calculating how many homicides [or suicides] would be prevented by a community treatment order.’ (8) In fact, the proposals in the Mental Health Bill could make things worse. It is hard to make a case for those assessed as posing little or no risk being put on community treatment orders or detained indefinitely, and those not in contact with services are likely to be less inclined to seek such help if they are aware of the implications for their civil liberties.

If it is fairly easy to refute the ‘scare in the community’ argument and the dangers of more coercive government legislation, it begs the question as to why such legislation seems likely to be pushed through. Part of the reason may be the blinkered nature of many of those campaigning against the proposals. The most common way that mental health campaigners criticise these figures is to show them relative to other dangers. So, for example, the figures above show that 91 per cent of homicides are committed by someone without a mental disorder. A briefing by mental health charity Rethink points out that each year 3,000 people die on the roads, 300 at work or by dangerous driving, 100-200 are victims of domestic violence, and so on (9).

Whilst I can see the rationale for this approach I’m not sure how helpful it is to substitute one scare story for another. For example, it is not just the dangerous patient we are told to fear, but virtually all adults (as personified in the rise of criminal records checks for almost anyone who goes near children) (10). If all adults are a threat to me and my children, why should I trust an ex-patient?

Such moral panics interact and feed off each other, increasing the sense that we are constantly at risk and in need of further ‘protective’ legislation. In these anxious times, perhaps a more co-ordinated approach to such scare stories is required.

Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England.

(1) Mental Health Bill 2006, UK Department of Health

(2) Report of the independent inquiry into the care and treatment of John Barrett

(3) Avoidable Deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness, University of Manchester

(4) Mental Health Bill 2006, UK Department of Health

(5) See David Brindle, New bill is leaner, but many say meaner, Guardian, 22 November 2006

(6) Whilst my criticisms also pertain to suicides, for reasons of space I concentrate on homicides here as I would contend that it is this fear that is the main driver of government policy, although the figures do illustrate that psychiatric patients are far more likely to kill themselves than anyone else. In addition, there were 235 (approx. 41 per year) unexplained patient deaths in Hospital.

(7) Taylor, P.J. and Gunn, J. (1999) ‘Homicides by people with mental illness’, British Journal of Psychiatry, vol. 174, pp.9-14.

(8) See ‘Avoidable Deaths’ p.93 and p.139 respectively.

(9) For example see Briefing – Severe mental illness and violence, Rethink

(10) See The Case Against Vetting: How the child protection industry is poisoning adult-child relations, Manifesto Club