That’s not to say Risk Assessment can’t have a place. After all, we accept the use of parole boards and probation services for the rehabilitation of criminal offenders.
Here in my part of Oz, mentally ill offenders can only have leave approved by the MHRT. When a person breaks the law in the context of a mental illness, it’s no longer a clinical decision as to whether someone is suitable for leave and all leave conditions are determined (increased, decreased or remain the same) by the MHRT at 6 monthly meetings.
Recent news has us once again reacting for our Risk Assessment calculator (that should say ‘reaching ‘ but oddly it doesn’t). Darren Harkin, a 21 year old who was resident of a low secure unit has been charged with the rape of a 14 year old girl after absconding. Darren is reported to have Autistic Spectrum Disorder. Not specifically a ‘mental illness’ – more of a mental disorder – but “he’s not normal” so he must be a mentalist.
Before I continue, a word of sympathy to the victim of this event; an event that no one disputes should not have happened. Though this posting may be somewhat anti-reactionist, I do not wish to minimise the nature of the events that have taken place.
The case highlights failures in a system which is backed up by an investigation carried out by reporter Nicola Stanbridge. The Today programme found that at least 94 patients escaped from medium and low secure psychiatric hospitals, or while under the escort of hospital staff last year.
Good work Nicola.
In response to the inevitable headlines, Louis Appleby has written a rather splendid piece in the Gunirada which reviews his interview on The Today Programme bashing stigmatism and reactionism [is that a word?]
In my interview I tried to explain how in mental health, unlike prisons, we have to strike a balance between care and security – against a tide of interruptions, hostile questions and incredulous asides, all the things that are so entertaining when they happen to someone else. What listeners would have concluded from the ensuing row is hard to tell. My nine-year-old said later, “I heard you on the radio arguing with that man.” Then he added, “Like you always do.”
Which somewhat differs from the Times Online report citing Uncle Louis as stating:
England’s director of mental health care today called for tougher standards for secure hospitals after it emerged that at least 116 mentally ill criminals escaped last year, more than 20 times the rate of escapes by offenders held in prison.
What appears to be the case, and this is the interesting part – is that Harkin was subject to a Restriction Order (s41 MHA) or similar.
In court, Judge Nicholas Cooke QC asked how Darren Harkin had managed to meet Home Office criteria to be housed in a low secure unit, having absconded three times from his medium secure unit and displayed destructive and aggressive behaviour
So if anyone wants to know how Harkin managed to get to being housed in a low secure unit – it’s because the Home Office said he could be. Of course, circumstances change and he may well have become more at risk. However, there are already many protocols in place for management of such offenders and, I really hope this do not lead to another level of counter-therapeutic security scrutiny and supervision.
In fact – isn’t it about time that the justice services picked up the supervision and monitoring role of managing “mentally ill” offenders in the community and stop this prejudicial treatment of the staff charged with their care? Mental health professionals are not trained to do anything that impedes the patient’s progress; we are by definition trained to do the opposite.
In what way are the justice services better equipped to deal with the mentally ill than psychiatric services?
Incidentally, you neglected to mention that Darren Harkin also has a diagnosis of schizophrenia, hence his being under the care of psychiatric services.
Yes I did forget that part. Tho schizophrenia is an attribute of ASD that is often misdiagnosed as a separate entity (IMO) I did read it then forgot (possibly because schiz in ASD is usually ‘diagnosed’ to justify the use of antipsychotics under Form39 where capacity is impaired?). Thanks for the correction however.
He was resident in a National Autistic Society residence at the time tho but would have been subject to MH supervision under the MHA.
There’s an assumption in your first response that psychiatric services are equipped at all. Granted much work has gone into the development of tools and theories etc – but to then charge the mental health services with the determination of who is fit to mix in public or not – is not exactly a clinical exercise. The same tools can be used by other parties to make the same determinations. To ask a clinician to make what is essentially a counter-therapeutic decision when restricting leave, determining placement or dictating community living conditions – even decisions on the enforcement of medication too perhaps?; how are any of these beneficial to the therapeutic relationship?
Let me take another clinical example in comparison:
An optometrist cannot tell a patient they are not allowed to drive even if their eye sight fails the driving standard:
‘When a patient does not meet driving standard requirements, you can only advise them about it. Your duty is to make sure that they are aware of the clinical results. You are not in a position to tell them whether or not they are allowed to drive’.
http://www.ukoptometry.co.uk/u.....standards/
[This is not the complete process - but essentially it is true]
Responsibility rests with the Medical Advisers at DVLA to apply these standards and decide whether a person is fit to drive. The law governing the issue of driving licences is contained in the Road Traffic Act 1988 and the Motor Vehicles (Driving Licences) Regulations 1999.
http://www.dvla.gov.uk/medical/about_dri_med.aspx
Tho there is a general ‘duty of care’ this is far easier than “You WILL assess, manage and strand accountable for ALL all risks”.
Even the GMC guidance [which cites an example as a 'mentally unstable' person] gives the responsibility to the patient in the first instance
Q17 A patient of mine suffers from a serious mental illness. He is often erratic and unstable. I know that he drives, although I have warned him that it is often unsafe for him to do so. He insists that his illness does not affect his judgement as a driver. Should I tell the DVLA?
The DVLA is legally responsible for deciding if a person is medically unfit to drive. The Agency needs to know when driving licence holders have a condition which may now, or in the future, affect their safety as a driver.
Where patients have such conditions you should:
a. Make sure that patients understand that the condition may impair their ability to drive. If a patient is incapable of understanding this advice, for example because of dementia, you should inform the DVLA immediately.
b. Explain to patients that they have a legal duty to inform the DVLA about the condition.
If patients refuse to accept the diagnosis or the effect of the condition on their ability to drive, you can suggest that the patients seek a second opinion, and make appropriate arrangements for the patients to do so. You should advise patients not to drive until the second opinion has been obtained.
If patients continue to drive when they may not be fit to do so, you should make every reasonable effort to persuade them to stop. This may include telling their next of kin, if they agree you may do so.
If you do not manage to persuade patients to stop driving, or you are given or find evidence that a patient is continuing to drive contrary to advice, you should disclose relevant medical information immediately, in confidence, to the medical adviser at the DVLA.
Before giving information to the DVLA you should try to inform the patient of your decision to do so. Once the DVLA has been informed, you should also write to the patient, to confirm that a disclosure has been made.
http://www.gmc-uk.org/guidance.....aq.asp#q17
I’m sure GPs and the like are quite happy not to have to determine and action the cessation of someone’s driving license – yet they are part of the process.
Why can’t mental health clinicians have that same distance from such counter-therapeutic actions as determining leave or where to live when the only concern for such decisions is ‘public interest’?
how are any of these beneficial to the therapeutic relationship?
There you go, assuming that a therapeutic relationship cannot be engendered even in the circumstances of restriction, forced medication etc. That, I’m afraid, speaks to a lack of imagination IMO.
You’re making a circular argument. I didn’t say clinicians CAN’T do it – I’m saying WHY SHOULD THEY?
Why should I have to work even harder at my therapeutic relationship with a person because the powers that be determine it’s also my job and my accountability to make sure everyone else is safe too?
And what is it that says a nurse, psychiatrist or psychologist is the best equipped professional for determining risk to public safety? And if this is the case – why aren’t we doing all the parole board reviews too? What are all these legal and lay people doing there? All they do is assess risk to the community.
Under the current MH model of s17 leave – the penal system would run something like the prison officers and governor determining when someone is fit to be paroled. And they’d be held accountable for any prisoner who re-offended.
In regards a lack of imagination – I’m looking to a future that removes the existence of power and control from clinicians; the inequality of how people with MI are treated as a sub-class – suffering more scrutiny, restriction and detention than even a rapist. I’m talking to changing something that hasn’t changed in 300 years.
To not imagine change is to accept the status quo – which is not only lacking imagination but is living in denial that there is anything wrong with things as they are.
So tell me, if I’m wrong – how are any of these beneficial to the therapeutic relationship?
So basically you want to dump the unpleasant parts of the job onto someone else, despite the fact this would place an almost intolerable burden on people who are not really trained to deal with mentally ill offenders.
And if you say you should train them to deal with mentally ill offenders, why would any government order that when they already have a large workforce of expensively trained personnel who could do the job?
I am somewhat bemused that the Hays took Harkin in the first place, considering his index offence and dual diagnosis. There’s been quite a lot of discussion about this, amongst us NAS members, but senior staff are “waiting for the results of the inquiry” before commenting. From the comments I’ve seen, the membership do not seem in a forgiving mood. The NAS chief executive may come to rue the day he left the Womens’ Institute top job to work with us, whom I’d imagine he thought were a bunch of dribbly kids, and quirky computer nerds.
PS The results of the Scottish Prisons’ PDD prevalence study will be published next week. My prediction is that it’ll be 6 – 8%. The autistic stereotype is going to take another battering.
beakie: Yes I do want to dump this unpleasant part of the job on someone else. But on a logical basis that custody is contrary to care. So why charge the clinicians with the conflict of interest decisions?
What basic training is there for clinicians exactly for risk management in ‘mentally ill offenders’? I’ve met about 5% of clinicians who really have a grasp of risk management against therapeutic advancement. There is no education in grounding theories of moral responsibility; social control; sanctions; rights vs responsibilities; etc.
Those without this grounding tend to err on “saving my arse by not taking risks with a patient that I don’t have to”
Dr Mezey is just one example of how compromised a clinician can become when trying to balance individual clinical decisions against public safety. She know faces multiple charges and potential loss of career – and at the time the patient wasn’t even detained as an offender.
The intolerable burden; not really trained – that’s exactly what I’m saying MH services have. Plus our purpose is the complete opposite – the patient to regain independence.
Clinicians are trained to deal with MH. Probation, judiciary and police are trained to deal with offenders. Sure, they might need a little expert guidance on MH issues (but I note MH has never had the expert support of any of these professions when dealing with offender issues and was left to its own devices) – but essentially they are judging if the presentation of this person compromises any risk to general public. It’s got nothing to do with the advancement of clinical treatment.
I still don’t see how retaining this role is of benefit to the patient as you argued.
Socrates: I’d be interested in that prevalence study when it comes out.
What you are effectively arguing for here is a dual provision for mentally ill offenders – a service providing the “nice” stuff like the talking therapies, the counselling, the warm fuzzies and one providing the “nasty” stuff like enforced medication, detention, risk assessment and so on.
You assume that a therapeutic relationship is required to provide the “nice” stuff, a relationship which is impaired by having to provide the “nasty” stuff alongside it. This further assumes that provision of the “nasty” stuff does not require a therapeutic relationship, and can therefore be delivered in its absence.
Except things do not work out as neatly as that in real life. Take risk assessment for example. It’s not simply a matter of ticking check boxes against a list of risk factors. In fact, that approach is completely inadequate, as it fails to take into account contexts that might mitigate or exacerbate risk. By far the best way of assessing risk is through historical and clinical assessment, which necessitates talking to the patient. Thus some sort of relationship is required to perform adequate risk assessment.
But also, there will be no nice warm fuzzies if the person doesn’t come into contact with your services in the first place, and doesn’t remain there when he does. So presumably, the staff providing the “nice” stuff will be able to trigger the “nasty” stuff should patients want to leave their units, or refuse their medication, or decline to participate in their therapy groups.
And what happens when a patient discloses ongoing compelling violent fantasies of murder and rape while in the middle of a session of the “nice” stuff? Do you ask him to keep that for the “nasty” providers who have to make decisions about his risk? Or do you communicate this information to the “nasty” providers, in the knowledge that his risk status will change with all the attendant sequelae? In which case, while you may think your own hands are “clean” and your “therapeutic relationship” is intact, the patient will be well aware that you can get the “nasty” boys to go into action whenever you want.
Your argument that mental health services are currently ill-equipped for managing mentally disordered offenders – apart from being something I should imagine forensice nurses might like to take you to task over – is not an argument for the development of an entirely new service, but for improvement of the current one.
What you are effectively arguing for here is a dual provision for mentally ill offenders – a service providing the “nice” stuff like the talking therapies, the counselling, the warm fuzzies and one providing the “nasty” stuff like enforced medication, detention, risk assessment and so on.
Well it’s funny you should argue that way beakie; as, apart form the enforced medication issue, this is exactly the way things are here in Oz.
However, it is necessary to deconstruct the risk process –
There is Assessment
There is Management
But inbetween the two there is a Decision.
In the UK this is a clinical responsibility alone.
Here it is different, as indicated in the opening paragraphs above, that the MHRT are a larger part of the Decision process:
Here in my part of Oz, mentally ill offenders can only have leave approved by the MHRT. When a person breaks the law in the context of a mental illness, it’s no longer a clinical decision as to whether someone is suitable for leave and all leave conditions are determined (increased, decreased or remain the same) by the MHRT at 6 monthly meetings.
MHA detention falls into two main treatment orders: Involuntary (civil) or Forensic (criminal). Those involuntary are subject to the same clinical processes as UK counterparts on s3 asthey are by definition to not be a ‘mentally disordered offender’. However, those on Forensic section have all the terms and conditions of eave set by the MHRT – comprising legal, psychiatrist and lay person as in UK. When they convene, the Attorney General office can oppose any MHRT recommendations and represents the pubic interest. AG can not dictate the MHRT decision – but can appeal against any decision they make. This allows the MHRT process to follow the adversarial process of usual legal pathways – rather than allowing the Home Office (AG equiv) to make unilateral decisions and rather than clinical teams to have to debate the issues amongst themselves.
When it comes to utilising that leave or conditions of discharge the MHRT consitently includes “subject to the due risk assessment of the treating psychiatrist” so it doesn’t obviate the clinical team responsiblity; but it does take that wider general decision away from the clinical team.
I’ve pros and cons for this system – namely:
Pro: No longer are clinicians making overall judgments of risk to community. We still manage it as determined by the MHRT but if a decision goes tits up – the MHRT have offered independent balanced review of the risk and it is they who have determined on it. The clinician’s therpaeutic role is not compromised in this modality as they simply present the detail (nice & nasty) to the tribunal in objective format.
Cons: When a patient presents an increased dynamic risk (eg absconds or numerous incidents) then for the time prior to the next MHRT, the clinicians remain responsible for managing dynamic risk – eg suspending leave. Conditional leave is not just subject to current clinical presentation but can also be weighted by local public opinion (eg sex offenders) or the nature of the crime (eg someone who commits murder whilst off their head on drug induced psychoses has a MH defence – in clinical terms they can be settled and off the order within a couple of months – but the MHRT doesn’t just consider clinical detail).
There are issues of ‘discovery’ and who determines how and what information is available. However, MHRT are not shy and will err on caution if the clinical team cannot supply an objective review of the patient/issue and insist on more information to make their decision.
The process still requires clinicians to inform on risk and to manage where risks are identified – but it doesn’t require us to make the general decisions on whether a person is fit for discharge – that is determined by the MHRT.
If a patient discloses “I feel like kicking the crap out of the martians who serve me tea and coffee in the local cafe” then of course we have a duty of care – but this is temporary management until such time as adminstrative review takes place – which may be requested earlier by any party.
So it would seem possible to externalise the process of making risk decisions and thus, in the case of the likes of Harkin, the clinicians do not carry the greater responsibility for the decision to allow that exposure – the administrative review body (be that MHRT or Parole Board or whoever) is equally, or more so, accountable.
When it comes to utilising that leave or conditions of discharge the MHRT consitently includes “subject to the due risk assessment of the treating psychiatrist” so it doesn’t obviate the clinical team responsiblity; but it does take that wider general decision away from the clinical team.
So quite how this improves the therapeutic relationship you think is impaired by such work is beyond me. Patients are still aware that their psychiatrist can block their leave.
So it would seem possible to externalise the process of making risk decisions
But they aren’t.
So quite how this improves the therapeutic relationship you think is impaired by such work is beyond me. Patients are still aware that their psychiatrist can block their leave
Yes indeed – but not to the same extent – and the psychiatrist nor the team are wholly responsible for making the decision on risk – which was my point – not the therapeutic relationship – that’s a side issue.
Me:So it would seem possible to externalise the process of making risk decisions
You:But they aren’t.
Me again: The MHRT are not an independent body external to the clinical team?
and the psychiatrist nor the team are wholly responsible for making the decision on risk
But they influence the decision, so the “nasty” is not entirely separate from the “nice”, and to suggest it is is incorrect.
The MHRT are not an independent body external to the clinical team?
See above.
But they influence the decision, so the “nasty” is not entirely separate from the “nice”, and to suggest it is is incorrect.
Of course we remain involved. We feed the objective honest information to the MHRT; MHRT stipulates what they consider the risks to be; we work with the patient to identify ways to overcome them.
Suggesting we don’t get involved in the nasty stuff is like saying generic nurses don’t have patients who die on them or endure horrible suffering through their treatment.
See above.
How far above? I see a cottage in the wilderness….
So now you’re arguing against yourself – you do not operate a service where the “nasty” is divorced from the “nice”. You also seem to be indicating that nurses should be prepared to be involved in the “nasty”, which is not what you were advocating in the post itself, where you envisaged all the “nasty” stuff hived off to – oh, someone else, anyone else but not us because of our precious relationships.
(beakie: I took the liberty of editing as requested of Z. Hope as intended.)
I’m not arguing at all – I’m saying that’s how it is with the MHRT and Oz.
I found it useful to make the stark comparison with probation and parole services to indicate prison officers and governors do not make the judgment decisions on risk and release of prisoners.
Do you consider the parole board system to be flawed?
Perhaps they should allow prison officers or clinicians to assess suitability to return to the community?
Remember what it was like as nurse in charge and making a clinical decision? Even if the outcome was good you could feel so alone and under scrutiny – yet when a team made a clinical decision it felt more ‘safe’?
MHA detention is a legal administrative process and no member of the clinical team is specifically trained in law.
Currently the parole board consists:
The Parole Board holds two types of hearing: Oral hearings
These normally take place in prison. They will usually be chaired by a judge, but in some cases by a legally qualified or experienced Parole Board member. Where the circumstances of the case warrant it the panel will include a psychologist or psychiatrist. The third person will be an independent, probation or criminologist member. [Emphasis added]
Essentially a parole board offers an inmate the same as a “s25″ supervised leave with conditions.
So why do criminals have legally qualified members (to not only judge but to act as adversaries) yet clinical teams who decide on legal ethical issues at meetings have only themselves as clinical team members and no legal or even community representation?
I’d much prefer to see the hybrid model of health and justice departments as offered on parole boards being used for mentally ill offenders also. Currently it’s all Health and no Justice.
source: http://www.paroleboard.gov.uk/....._hearings/
Currently it’s all Health and no Justice
Because MDOs are patients being treated, not prisoners being punished.
Prisoners are being ‘rehabilitated’ – far from being punished – but that’s a whole other debate (It’s not – but don’t need to over-complicate this one any more).
Because MDOs are patients being treated,
There are a number of connotations to the use of that word in this sentence…. but surely you’re not arguing incarceration is a part of mental health ‘treatment’ to improve the individual?
If they were being merely ‘treated’ the term “mentally disordered offenders” would not exist – they would be just mentally ill and not have their own class of (s37) detention order with optional (s41) Home Office restriction.
The MHA exists for the enforced social exclusion of patients as well as enforced treatment – just like prison – for the lawful removal of a person’s liberty.
Is there some purpose in avoiding the issue that psychiatry is coercive and locks people up to preserve wider society? It’s not all about the person.
but surely you’re not arguing incarceration is a part of mental health ‘treatment’ to improve the individual?
Sometimes it is, yes. Being away from all the pressures and stresses of being in the community can be therapeutic. Having structure, boundaries and rules can be therapeutic.
If they were being merely ‘treated’ the term “mentally disordered offenders” would not exist
Well, they are. The term indicates that they have offended, not that they are being punished.
Is there some purpose in avoiding the issue that psychiatry is coercive and locks people up to preserve wider society?
But that wasn’t the issue per se. Unless suddenly it is?
But that wasn’t the issue per se. Unless suddenly it is?
It just seems that there is no fault for you with the current system. Everything is hunky dory and the patient is getting their due representation and the clinicai team is doing a damkn fine job of decision making on risk.
I strongly dispute this is the case and further resent the fact that ‘risk’ was increasingly dumped on psychiatry over the last 20 years. Some people ran with it and made it their career.
Now things are more developed and clearer appreciation of the issues involved – and with acknowledgment not only that risk rarely promulgates a clear cut solution (someone always loses) but that the risk management component overtook the importance of ‘treatment’ there for a while, – there now needs to be an overhaul of the process so it presents a more equitable and robust system than a group of clinicians making independent judgments.
“Risk” was a knee jerk development of systems and services that was forced upon psychiatry in response to social need.
I agree that risk is an issue, that decisions need to be made. I contend the system was bodged by culturing this isolated process and it’s time it was reviewed.
It just seems that there is no fault for you with the current system.
Disagreeeing with your proposal to hive off the nasty bits of the job to someone else does not imply that I believe the above. Stop erecting straw men, Mr Ian.
Risk assessment, far from being “foisted” on psychiatry was always an integral part of it. Long before the “risk assessment industry” came into being, clinicians were making judgements on people’s level fo risk. There’s an argument that we didn’t do it very well, and continue not to do it well. There’s also an argument that public expectation of what risk assessment can achieve is at odds with reality: a mathematical model has yet to be produced that accurately predicts the behaviour of two balls when a third strikes them; predicting human behaviour with any degree of exactitude is impossible.
However, neither of these present any convincing argument for placing that responsibility anywhere else. The likelihood is that nobody could do it any better or worse. Parole boards release people who go on to kill. Probation officers fail to prevent some offenders from reoffending. The only argument for making someone else do it is that you want someone else to take the blame when it goes wrong.
The only argument for making someone else do it is that you want someone else to take the blame when it goes wrong.
Absolutely. But I have opined a hybrid model of responsibility and involvement. I don’t see why it has to be psychiatry/mental health alone.
The impetus for this post was from the media represented reactions to Harkin’s case:
England’s director of mental health care today called for tougher standards for secure hospitals after it emerged that at least 116 mentally ill criminals escaped last year, more than 20 times the rate of escapes by offenders held in prison.
I am proposing such tougher standards be achieved through sharing the burden with a wider scope of professional responsibility who have a wider reference to relevant knowledge, skills and understanding – and not sticking with the status quo or stacking more responsibility on the already over-responsible psychiatric services.
You oppose that suggestion stating it shouldn’t be someone else’s responsibility. Not sure how you stand on the hybrid model.
I’d accept any suggestion for psychiatry to continue if the service could determine some level of moral reasoning (and understand why) to the process instead of the individualised preferences and reservations of people who have little understanding of the principles involved.
Or do you equally opine that MH services sufficiently educate the clinical staff on such matters?
Or perhaps that mentally ill offenders don’t engender the same ‘need’ as non MI offenders and don’t require such level of services?
Offending is offending and the process of moral reasoning is no different betwixt one kind of person or another. Impairment does not invalidate the moral reasoning process – it falsely informs it – and thus the mainstream principles of risk and morality remain valid for those with MI as those without. As do the principles of social control and public safety.
To improve the services, and as MH services are trained in doing ‘care + treatment’, we need to develop the awareness beyond the current layman’s understanding of the role and process of “risk management” that is effectively no more than ‘social control + policing’.
Currently I know of no guidance, training or ethical standards in psychiatry that provides this. Sure I can assess risk, I can formulate management. But I am not formally educated or trained in how to determine the balance of risk to public against right to independence. Neither is my psychiatrist or psychologist. I have no idea what my community expects of me or what is happening in the next community in terms of where lines are drawn. It’s unique to each practising clinician and local team.
There is no innate knowledge we have; is it simply acceptable that MDO’s do not deserve decision makers of the same level of education and awareness of such matters as a criminal does?
A magistrate or judge is aware of the role of satisfying the public yet improving the person. This is why they do things that seem to not reflect well in public opinion – such as sending a burglar for drug counseling rather than incarcerating them. Yet when that burglar re-offends, the judge is not (or very rarely) criticised openly and individually.
This is why I see the hybrid as being a more likely successful alternative to this; because those with understanding of social control and ‘policing’ are generally able to morally reason better because they are trained to and they are also afforded a better level of indemnity for their unfortunate decisions.
A comparable article to those read on MDOs (ore even non-offenders) who escape from hospital (tho they have not all re-offended:
Public confidence in the supervision of high-risk offenders released from prison suffered a fresh blow yesterday with the disclosure that 83 have been charged with a further serious offence, such as murder or rape, in the last year.
The figure for 2006-07 compares with 61 high-risk offenders who committed further serious crimes while under the supervision of the probation and police services in the previous year.
[2007]http://www.guardian.co.uk/uk/2007/oct/23/ukcrime.immigrationpolicy
And further, an individual example:
A convicted kidnapper who committed other crimes while on parole caused a headache for a District Court judge as he had to second guess the parole board.
As parole officials have yet to deal with Steven James Freeman’s breach of parole it left Judge Michael Shanahan to in effect guess what the parole board would do with Freeman.
[2008]http://www.news.com.au/couriermail/story/0,,23735593-3102,00.html
Nowhere does the parole board get criticised for letting him out early – yet he obviously wasn’t rehabilitated.
Dr Mezey could have surely enjoyed the existence of such luxuries in psychiatry?
I think your hybrid model has huge risks attached to it. In every inquiry you read, lack of communication between staff and between agencies appears as a problem to some extent. Increasing the range of people involved increases the complexity of communication and thus increases the possibility of the kinds of miscommunication that lead to problematic and dangerous situations arising.
There is also a risk that responsibility for decisions becomes a ping pong ball batted back and forth between professionals with nobody willing to carry the can and no decision being made.
You also increase the risk of diluted responsibility such that nobody feels responsible or accountable for decisions made, so either unwise risks are taken or no risks at all.
Health and justice work to different criteria. Given that two groups of healthcare professionals can clash due to differing agendas, bringing in someone from an entirely separate discipline seems a recipe for disaster.
Attached risks – the current one is hardly robust.
Responsibility – And? At least they’re not pinning one clinician to the wall. If other professions don’t have this individualised responsibility – why should psychiatry?
Diluted responsibility – yes. This is the cost of increased input . I think increase gain over-rides dilution loss and stands to redress the inadequacies of the current system.
Different criteria – Absolutely my point – they shouldn’t be. There is no reason a psychiatrist should determine on one type of person’s danger to society and a varied panel on another’s. Any inequitable treatment is prejudicial.
You seem to have carefully avoided the huge risks involved in poor communication. If people can’t communicate properly within the same team or the same local area, how does it improve things to introduce a whole slew of other agencies to communicate with?
Absolutely my point – they shouldn’t be.
Eh?
Damn pressed send too soon. You seem now to be under the impression that a psychiatrist makes decisions about a person’s risk in complete isolation.
Not a slew – an amalgamation with those who already have systems in place doing virtually the same job.
You seem now to be under the impression that a psychiatrist makes decisions about a person’s risk in complete isolation
Yes I am – because they do. The point is, psychiatrists form an opinion based on information given. That’s fine and that’s part of their job and that is the collective opinion. But they independently make the decision for which they carry a professionally isolated and singularly individual responsibility. I’m not sure how you believe that anyone other than the psychiatrist is responsible for the decisions made by the psychiatrist. To challenge the decision of a psychiatrist is something only happens when law or serious breach of ethics is involved. There is no equivalence of power or responsibility to that of the consultant psychiatrist with any other clinical profession.
You’ve read the Dr Mezey case I’m sure – and granted that the pt concerned wasn’t even a MDO – he was under a s3 section (which show as that even non MDOs attract significant recourse if decisions are called into question). She was isolated out by the inquiry report as being singularly responsible for the man being out on leave, despite her gleaning MDT opinion from available sources. So, yes – they do, as evidenced by this and many other damnations against psychiatrists, make decisions unilaterally (tho the new MHA Authorised Practitioner will potentially change all that).
An additional representation by the judicial services in the matters of community exposure and repatriation would balance that power and responsibility and not leave the psychiatrist high and dry.
Not a slew – an amalgamation with those who already have systems in place doing virtually the same job.
But they aren’t. Parole board decisions are made on the grounds of whether the person is considered “rehabilitated”, whether they show appropriate remorse for their crimes, whether the board believes they will do it again or not. This is very different from considering someone’s mental state. What you are asking for is for the sticking together of two disparate groups who speak totally different languages, have totally different goals and totally different methods and asking them to work towards the same end.
Yes I am – because they do
No they don’t.
She was isolated out by the inquiry report as being singularly responsible for the man being out on leave, despite her gleaning MDT opinion from available sources. So, yes – they do, as evidenced by this and many other damnations against psychiatrists, make decisions unilaterally
What a strange way of arguing your case! This psychiatrist did not make a decision in isolation, but because she was considered by the inquiry to be solely responsible for the patient being on leave, that somehow proves she DID make the decision in isolation? There must be a name for this kind of logical error.
This is very different from considering someone’s mental state.
Mental State is a component of mental health that looks specifically at mental illness traits. This is the prerogative and responsibility of the MH service.
But parole boards are furnished with expert psychology reports just as MDTs are. They do not have a different set of tests and criteria – they all point to cognitive state, attitude and ability to reason.
Else, by just what processes do criminals demonstrate rehabilitation if not cognitive mental ones?
Parole and s17 Leave are much the same. There is a clinical aspect to the use of leave, absolutely – as there is a rehabilitation aspect of parole – parole is often used as an aide to rehabilitation – hence it is also therapeutic
“Make risk assessments which are rigorous, fair and timely with the primary aim of protecting the public and which contribute to the rehabilitation of prisoners where appropriate.”
Aside ‘treatment’ or ‘rehabilitation’ (which are interchangeable terms applied under different conditions – and indeed s17 is used for community “rehabilitation”) the other issue of concern, as with parole boards, is – the protection of public safety which is not a clinical matter and belongs to those charged with a duty of protection of others, namely the justice services.
The parole board utilises expert psychiatric and psychological input in it’s decisions making as necessary. Why does the clinical team not have equitable access to legal input?
Stakeholder meetings now include in some cases police liaison services which indicates it’s not all about clinical matters. But a police officer does not have the same level of power and responsibility as a psychiatrist in any decisions. It is also argued that MHA and services, by not having equitable processes and provisions are treating mentally ill people prejudicially. This is a swings and roundabouts point for as many MH patients who gain – others will lose. What will change tho is the process of accountability so that MH services are treated more equitably in line with other public safety decision makers and not be individually liable for those decisions.
What training, guidance or knowledge do any of the clinical MDT have on the duty of public protection?
As for the decision making – I am astounded to find you do not grasp the simple difference between who informs the decision – and who makes the decision. The final say is with the psychiatrist – period. Regardless of how well informed or not they are; if two different stream clinicians agree on something and decide an action – and one of them is a psychiatrist – the other clinician is not expected to have known better than the psychiatrist if it goes wrong. The psychiatrist remains responsible for their patients and ALL decisions relating to their care and will be expected to have made the decision independently and without the persuasion of another.
I’m sure however that our Honourary Nurse Shrink and his colleagues would be content to know that if he’s part of a clinical team decision he can now point the finger at someone else.
As regards Mezey’s decision to permit the patient to go on leave – the only way her decision would not have been made in isolation would be to confer with a psychiatrist colleague or professional senior. No other profession has that legal or clinical or operational authority to make that decision.
Your position that decisions are made by a collective is fundamentally flawed. A nursing shift leader cannot hold their junior staff responsible for a decision they made when given all the facts. A psychiatrist cannot hold any other clinician responsible for a decision they made.
That’s why we write in clinical files about who decided what – as “who” has no clinical relevance to the treatment – it is only for legal and operational issues.
*facepalm*
We are going to have to agree to disagree, mainly because I’m getting a little bored with the circularity of the arguments and your goalpost-shifting behaviour.
I object to accusations of goal post shifting but given your understanding of ‘decision making’ I don’t expect you to understand my argument either.
I can concede to agree to disagree. Your stubborn-ness in argument is exemplified by your resistance to change in practice.
It is odd you oppose such change – this is the exact practice where I work. It presents none of the hyperbole you raised and does provide a robust system that reduces the liability of the treating team and specifically, as the clinical leader, the psychiatrist.
your resistance to change in practice
Again with the straw men. Disagreeing with your proposal does not mean I am resistant to change in practice.
By itself, of course disagreeing with a proposal does not indicate resistance to all change – but when your whole argument is based on flawed principles to defend your position of “why change something just cos it’s broken?” – kinda lends itself to the notion you’re creating hyperbole out of either a fear of change – or enjoyment of failure, rather than an objective opinion.
What a bizarre conclusion to come to. I am in favour of WORKABLE change to practice. Your proposal is not workable.
Do you not read very well?
It’s been in practice here for 6 years.
But I’ll pop and tell the State government beakie says it won’t work.
I’ll elaborate the process a little more. Initially I disliked this system – as it requires more rigorous review of the patient’s treatment and condition. I’ve come to realise and accept this is the very reason it exists and in fact places more responsibility on the treating team to come up with some sensible and plausible risk management strategies.
Essentially, all detained patients are reviewed by MHRT a minimum of every 6 months as per normal international standards. The MHRT is also standard: 1 legal; 1 psychiatrist and 1 lay person.
Civil sections (s3 equiv) have their orders reviewed and either upheld or revoked.
But MDOs (s37 equiv) have the order and the availability of (s17) leave reviewed. The MHRT set parameters and conditions for the extent of that persons leave subject to the review of the patient’s clinical presentation; internal risk assessments and any risk management strategies the team suggest – treating psychiatrist also gives opinion and makes a request – as can the patient – for the level of leave desired.
Following deliberation, the MHRT then determine if the patient may have leave and at what level:
eg on hospital grounds only; off & on hospital grounds; overnight – right up to granting of full discharge.
They determine if these are to be escorted by staff or unescorted.
They also determine if the patient requires Health service staff or can be accompanied by non-HS staff (such as non-government community lifestyle workers)
They place tacet conditions such as – no alcohol; compliance with treatments – and always include “to be implemented at the discretion of the treating psychaitrist subject to appropriate risk assessment”
During the MHRT, the tribunal will also hear from the Office of the Attorney General Office if they wish to represent public safety interest. AG will always be present for a special interest (s41 equiv) case.
The MHRT make the decision whether this person is suitable for community exposure and at what level and with what conditions. Thus if the psychiatrist permits access to leave – it is not they alone that made that decision. It is first the MHRTs responsibility.
It doesn’t slow anything down in terms of length of stay or treatment opportunities. It only increases the clinical teams need present well thought through integruous risk assessments and corresponding management plans.
It is a fair and robust system that reduces the clinical team responsibility by applying formal administrative review to the process and significantly reduces the psychiatrists conflict of ethics in decision making.
It’s been in practice here for 6 years.
No it hasn’t. The Australian system is nothing like your proposal. The MHRT is nothing to do with the criminal justice system, it is not a parole board nor is it composed of criminal justice professionals.
I concede.
There is no way I can debate with such ignorance.
Now put the keyboard down and go get an adult for me to talk to.
Is the MHRT part of the criminal justice system? No. Who sits on the MHRT? A legal person, a psychiatric professional and a lay person. That is a very different beast to your proposal in your post for criminal justice to manage MDOs – and I quote –
“isn’t it time the justice services picked up the supervision and monitoring role of managing “mentally ill” offenders in the community…”
I’m sorry if you are unable to track the progress of your own argument and have to resort to ad hominem remarks.
Tracking the argument will be easier if you weren’t riddled with so many misconceptions and misunderstandings.
I have not proposed criminal justice – simply justice.
Justice in the UK already monitors – and determines on – restricted patients movements and community exposure. This does not extend to s37 non-restricted patients for some reason.
For some background reading I recommend:
http://www.wikimentalhealth.co.....of_Justice
http://www.ajtc.gov.uk/index.htm
(Administrative Justice and Tribunal Council)
These MoJ guys review Administrative Law and Tribunal processes – which includes, amongst other Acts, the MHA2007.
As a rough guide:
MoJ is the parent of the Mental Health Unit (formerly Home Office MH branch)
http://www.mentalhealthunit.com/mhuguidance.html
However, their role extends only as far as:
http://noms.justice.gov.uk/new.....iew=Binary
The Ministry of Justice Mental Health Unit only deals with psychiatric patients detained under the following Mental Health legislation:
• Sections 37/41 of the Mental Health Act 1983;
• Sections 47/49 of the Mental Health Act 1983;
• Sections 48/49 of the Mental Health Act 1983;
• The Criminal Procedure Insanity (Unfitness to Plead Act 1964 (CPI)); and
• Section 45a of the Mental Health Act (Hospital Directions)
These are all part of the Justice group and serve to protect the safety of the public. It says so on the top of the page.
Further, and essentially, if there is concern over the safety of the public for MDOs – then surely their responsibility to “protect the public” extends to s37s under their MoJ responsibility?
To not be involved suggests there is insufficient risk to the public to require intervention.
Otherwise, there is an irrationality to having clinical teams doing such elaborate assessments and strategies in the interests of public safety and then holding them accountable for errors of judgment – when you have a whole unit within the MoJ who self proclaim to be “managing mentally disordered offenders to protect the public” that doesn’t even get involved in the review process.
“s37 MHRT? Sorry, we don’t get out of bed for anything less than a s41″
I have not proposed criminal justice – simply justice.
So just any old justice professional then – a family lawyer or a specialist in shipping law, maybe? Or maybe a team made up of copyright lawyers. Who do you think would be best qualified to deal with MDOs?
The reason the MoJ MH Unit restricts itself to restricted patients, so to speak, is because restricted patients need Home Office approval for any leave/transfer/discharge. Patients not on Home Office restrictions are managed by their own teams. Section 37 patients are not only housed in secure units, but in ordinary acute wards these days and are many in number. The system would grind to a halt within days if the Home Office had to deal with them as well!
So just any old justice professional then – a family lawyer or a specialist in shipping law, maybe?
What? Why do you resort to imbecilic argument? Are you missing OSB?
So now your next argument is system meltdown?
The reason the MHU restricts to restricted patients is because the MHA 2007 makes no provision and ergo no lawful duty or responsiblity for non-restricted patients. Whether the system would grind to a halt or not is irrelevant – as it was when the MH services became accountable for managing DSPD patients and is now backlogged with patients who cannot be housed outside of secure units due to clinical risk assessments and lack of appropriate risk management options.
The reason Dr Mezey did not assess John Barret before he murdered Dennis Ferguson was because if she assessed every patient personally for every issue – her service would grind to a halt. And the same argument can be applied to every MDO or MH non-offender who offends.
If system capacity is an issue that absolves justice of protecting the public – then really the public should stop complaining about MH services who don’t properly prevent people with MI offending – because really MH services just don’t have the resources to manage them all in such depth.
Ooh… look what I found on the NACRO site….
Welcome to the Nacro Mental Health Unit website. Nacro is the leading criminal justice charity in England and Wales. Our Mental Health Unit aims to improve responses to defendants and offenders with mental health issues. Nacro believes that responses should focus on care and treatment rather than punishment. To promote this we provide a range of policy development, information and consultancy services to individuals and the various agencies that have dealings with those with mental health needs across the criminal justice, health and social care sectors. Our key objective is to help develop effective policy and practice.
http://www.nacro.org.uk/mhu/index.cfm
What are NACRO doing dabbling in MH issues? Don’t they realise they’ll come grinding to a halt? And aren’t they involved in criminal justice – not shipping law? No? Surely not. Go tell them to stop . Quick. It’s not their job. What is it all coming to?
Dr Marcus Roberts, head of policy at Mind, said: “We hope that the transfer of responsibility for prisoners’ healthcare from prison authorities to the NHS will lead to higher standards of healthcare for prisoners,
Oh no! Health being delivered by the Health Service!! Surely the prison officers can do that and not bring the health system grinding to a halt with all that extra work. Just cos it’s Health’s responsibility…..
I’m done here. You’re ridiculous.
You certainly are done here. Straw men, illogical conclusions, irrelevant cut and pastes, goalposts shifting hither and yon, hysterical wibblings and nary a coherent argument in sight, all finally dissolving into a babble of ad homs. Well done, ten points.
Your method of argument is as unstable and wobbly as your substance of argument. Coupled with your imaginary straw men and falsely construed and represented concerns on my flow and relevance -
You’re argument represents nothing more than a pair of fake moobies.
(ok the ad hominems part was correct).
I note you are one of those who argue your point by falsifying the opponents position – without validation or logical construct to your own position. You bounce from pillar to post to find fault with your contestor by creating false argument; yet only to come unstuck with misquotes and poor attempts to redirect.
What’s next?
What’s next?
What would be nice is if you put forward a concrete proposal that didn’t change very five minutes with the twists and turns of the argument so that a real discussion could be had.
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