Out of mind

British psychiatrists are waiting nervously to find out if the new mental health bill will turn them into jailers rather than doctors
January 14, 2007

Everything about Shona suggested that she was in control of the situation, except for her fat lip. Calmly and rationally, she pleaded with the young psychiatrist to find a way of keeping Joe out of the locked ward. She and Joe were doing well together for the first time, she said. He was looking for work; he was even sharing his dole money with her.

"Ms Wilson," the psychiatrist replied tensely, "Joe's on a suspended sentence only because he persuaded the court that he regretted what happened, and that he's taking his medication. Now he comes in here and tells me that far from being sorry, he'd like to find the man he punched and stab him instead. I've got to do something."

"That's just his anger talking," she said, a choke in her voice. "JJ's never stabbed anyone in his life."



What was this relationship about? Joe James had thumped his girlfriend in the mouth the previous night, and here she was, the next day, begging to be allowed to take him back home.

"Look," Shona tried for the last time, "I know he won't admit it to you. To him, you're just a white guy in a suit. But he tells me when he hears the voices, and he's scared. The only reason he hit me was because I was going on at him to take the pills when we got in. He's trying; he's really trying."

A month ago, the young psychiatrist might have given more consideration to what Shona was saying. The psychotic features of Joe's condition were eminently treatable. When he stuck to his Risperidone, the voices quietened to a whisper, and he showed some insight into his own violent urges. In the past, he had accepted that there was a problem that might go deeper than his schizophrenic symptoms. Joe's record of petty crime had begun when he was14, after his parents split up. He had lived first with his father, who beat him up, and then in care. The young psychiatrist had discussed with him what it meant to have a personality disorder brought on by childhood difficulties and social deprivation. Joe had thought about that. "I'm fucked up because I've had a hard life, right?" he'd said.

But all this was before the young psychiatrist had picked up the report into the 2004 killing of Dennis Finnegan by a violent schizophrenic, John Barrett. Barrett had been born in 1963, the same year as Joe. With anxious recognition, the psychiatrist had noticed there were other similarities. The broken home, violent father, period in care and history of petty crime leading to convictions for minor assault. Barrett had even had a girlfriend who pleaded his case. The chief difference between Joe and John Barrett was that Joe had never used a knife. But now Joe, too, had made a threat in front of the psychiatrist.

There was a distinction in the inquiry that none of the media reports had bothered to observe. It stated that no fault had been found with the general psychiatric services Barrett received prior to 2002, when he was first arrested for stabbing three people. It was only after that, when taken on by forensic services—the field of psychiatry that deals with criminally violent patients—that the report exposed serious errors in the handling of Barrett's case.

But could it be that Joe was now in the same precarious state as Barrett had found himself in 2002, when he first used a knife? What if he wasn't taking his medication, as Shona claimed? If that were the case, it might be time to get tough and enforce treatment. The rewriting of the mental health bill, currently being proposed by the government, includes new powers for general psychiatrists to enforce what are known as community treatment orders. Under these proposals, patients would be forced to take their pills, or be taken in. Maybe that wouldn't be a bad idea. Perhaps Shona would even back it up.

But the psychiatrist was getting ahead of himself. If he were being honest, the Barrett inquiry had simply made him nervous about his own professional position. Joe was not currently psychotic. If Shona was right, and he was beginning to make progress at home, that would be best for everyone. Joe was not John Barrett, and probably never would be. Was it sensible to restrict his liberty because of a political storm demanding new legislation that would lock up people like him every time there were concerns? There are thousands of patients out there, suffering and shouting out their rage and frustration. Was the young psychiatrist to imagine each one of them as a killer in waiting? He was a doctor, not a jailer.

The proposed new mental health legislation is an attempt to address a real problem among a small number of violent cases. But it fails to distinguish between general psychiatry, the primary purpose of which is to care for the treatably ill, and forensic psychiatry, which attempts to contain the dangerously insane. This is the distinction that allows general psychiatrists to view patients as humans rather than risk factors. Most patients are not violent, and predicting the next John Barrett among them is a doomed statistical exercise.

The young psychiatrist took a deep breath and turned to Shona. "Tell me if he refuses to take his medication, and tell me if he beats you up again, or makes any more threats. If you can do that for me, I'll see what we can do for him." "Thanks, doctor," Shona replied.