Risk and defensive practice in psychiatry

1. Risk and defensive practice in psychiatry D B Double

2. David Clark, 1995 • “Much has happened since 1983. The number of people in mental hospitals over Britain has continued to decline. The attitudes … of denigrating public service, of running down public hospitals, building up private enterprise, and of mean-minded economising have filtered down through the NHS bureaucracy. ... Battered by public enquiries and outcries, pressured by harassed Ministers, [the administrators and managers] have reverted to the kind of administrative behaviour that marked the worst of the asylum days - issuing memoranda forbidding activities, putting up warning notices, setting up disciplinary enquiries and penalising staff who take risks or show initiative. Staff have learned to be cautious, to get everything in writing, to avoid initiative.”

3. Origins of community care • Numbers of people in psychiatric hospitals increased until a peak in the 1950s in the UK and USA and later in other countries

4. Origins of community care • Numbers of people in psychiatric hospitals increased until a peak in the 1950s in the UK and USA and later in other countries • Motivation was to make the traditional mental hospital more therapeutic

5. Origins of community care • "Dismay and disgust with the old asylum system"

6. Origins of community care • "Dismay and disgust with the old asylum system" • David Clark’s description of back ward at Fulbourn hospital in 1953

7. Origins of community care • Opening the doors of the psychiatric hospital

8. Origins of community care • Opening the doors of the psychiatric hospital • “Return to moral treatment”

9. Origins of community care • Opening the doors of the psychiatric hospital • “Return to moral treatment” • Hospital as a therapeutic community

10. Negative process of institutionalisation • “Institutional neurosis” (Russell Barton)

11. Negative process of institutionalisation • “Institutional neurosis” (Russell Barton) • Apathy, lack of initiative, loss of interest and submissiveness

12. Negative process of institutionalisation • “Institutional neurosis” (Russell Barton) • Apathy, lack of initiative, loss of interest and submissiveness • “Total institution” (Irving Goffman)

13. Dehospitalisation of mental health services • Traditional hospitals went into decline

14. Dehospitalisation of mental health services • Traditional hospitals went into decline • Alternative services developed (including psychiatric units in general hospitals, residential homes and day centres).

15. Dehospitalisation of mental health services • Many old long-stay patients grew old and died in hospital

16. Dehospitalisation of mental health services • Many old long-stay patients grew old and died in hospital • Bed numbers overall have steadily continued to decrease

17. Politics of community care • Many psychiatrists felt threatened by their perceived loss of power due to the rundown of the traditional psychiatric hospital

18. Politics of community care • Many psychiatrists felt threatened by their perceived loss of power due to the rundown of the traditional psychiatric hospital • Campaigning organisations, such as SANE, deliberately exploited public anxieties

19. Politics of community care • Initial concern was that homelessness was being increased among the mentally ill

20. Politics of community care • Initial concern was that homelessness was being increased among the mentally ill • Tack changed when evidence accumulated against this view to concern about public safety due to homicides by psychiatric patients.

21. Politics of community care • New Labour government decided ‘community care had failed’

22. Politics of community care • New Labour government decided ‘community care had failed’ • Debates about community care are no longer as polarised as they were in the past

23. Inquiries into mental health services • Scandals that uncovered mistreatment of patients in hospital

24. Inquiries into mental health services • Scandals that uncovered mistreatment of patients in hospital • eg. Ely Hospital inquiry

25. Inquiries into mental health services • Scandals that uncovered mistreatment of patients in hospital • eg. Ely Hospital inquiry • eg. Whittingham Hospital inquiry

26. Inquiries into mental health services Political response • (i) setting up of Health Advisory Service (HAS)

27. Inquiries into mental health services Political response • (i) setting up of Health Advisory Service (HAS) • (ii) renewal of promotion of policy of community care

28. Inquiries into mental health services • Shift from focusing on abuses and over-restrictive practices within institutions to anxiety about the lack of control in the community

29. Inquiries into mental health services • Shift from focusing on abuses and over-restrictive practices within institutions to anxiety about the lack of control in the community • Since 1994 health authorities obliged to hold an independent inquiry in cases of homicide committed by those who have been in contact with psychiatric services

30. Inquiries into mental health services • Tragic killing of Jonathan Zito by Christopher Clunis on London Underground led to the formation of the Zito Trust

31. Inquiries into mental health services • Tragic killing of Jonathan Zito by Christopher Clunis on London Underground led to the formation of the Zito Trust • Zito Trust closed following implementation of Mental Health Act 2007

32. Homicide inquiries • Can have devastating consequences for mental health services

33. Homicide inquiries • Can have devastating consequences for mental health services • Reinforces stereotype of the ‘dangerous lunatic’

34. Homicide inquiries • Can have devastating consequences for mental health services • Reinforces stereotype of the ‘dangerous lunatic’ • Public fears of the mentally ill are fuelled

35. Luke Warm Luke inquiry (Scotland et al, 1998) • Two volumes cost £750,000

36. Luke Warm Luke inquiry (Scotland et al, 1998) • Two volumes cost £750,000 • Luke Warm Luke (formerly Michael Folkes) stabbed to death Susan Milner in 1994.

37. Luke Warm Luke inquiry (Scotland et al, 1998) • Two volumes cost £750,000 • Luke Warm Luke (formerly Michael Folkes) stabbed to death Susan Milner in 1994. • Diagnosed as suffering from paranoid schizophrenia, in and out of mental health facilities since 1983.

38. Luke Warm Luke inquiry (Scotland et al, 1998) • Criticised the lack of communication in the community care team

39. Luke Warm Luke inquiry (Scotland et al, 1998) • Criticised the lack of communication in the community care team • Also criticised the decision to discontinue depot medication.

40. Luke Warm Luke inquiry (Scotland et al, 1998) • Criticised the lack of communication in the community care team • Also criticised the decision to discontinue depot medication. • Should have been discharged into a staffed hostel

41. Luke Warm Luke inquiry (Scotland et al, 1998) • Criticised the lack of communication in the community care team • Also criticised the decision to discontinue depot medication. • Should have been discharged into a staffed hostel • Attacks could have been prevented if admitted to hospital.

42. Luke Warm Luke inquiry (Scotland et al, 1998) • Unclear why Luke Warm Luke killed Susan Milner.

43. Luke Warm Luke inquiry (Scotland et al, 1998) • Unclear why Luke Warm Luke killed Susan Milner. • Simple view that schizophrenia is a biological illness that determines how a person behaves, especially if they are violent

44. Luke Warm Luke inquiry (Scotland et al, 1998) • History of serious violence, which antedated the illness, passed over without comment

45. Luke Warm Luke inquiry (Scotland et al, 1998) • History of serious violence, which antedated the illness, passed over without comment • Focus on mental health services tends to exclude the role of other actors in the drama.

46. Luke Warm Luke inquiry (Scotland et al, 1998) • History of serious violence, which antedated the illness, passed over without comment • Focus on mental health services tends to exclude the role of other actors in the drama. • Understanding complex cases requires an approach that goes beyond blaming.

47. Richard King Inquiry (Norfolk & Waveney Mental Health, 2005) • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004

48. Richard King Inquiry (Norfolk & Waveney Mental Health, 2005) • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004 • Known to mental health services in Norfolk since 1991 .

49. Richard King Inquiry (Norfolk & Waveney Mental Health, 2005) • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004 • Known to mental health services in Norfolk since 1991 • Panel concluded the homicide occurred because of mental illness and that although it was not predictable, it was preventable because he should have been detained under the Mental Health Act.

50. Richard King Inquiry (Norfolk & Waveney Mental Health, 2005) • Trust panel understood public expectation that mental health services should exert some control