Conference on Mentally Disordered Offenders
Carolyn Little is a freelance writer.
She has been a lifelong carer.
She is a member of NSF(Scotland) and was appointed to the
Board of Management of that organization in 2001.
At a conference on Mentally Disordered Offenders earlier in the year,
she gave an address on individual care, together with a handout.
ACHIEVING EFFECTIVE INDIVIDUAL CARE
A CARER�S PERSPECTIVE.
I am a �CARER� � this is not a label that I like. However it is a label that confirms that I am close to someone with a diagnosed mental illness. In this case it is �schizophrenia�. It could have been manic depression or a host of other terms.
Over the years I have met many carers and service users who feel awkward about being given a label that confirms a diagnosis of mental illness. But they are just that � illnesses.
Often however, there is reluctance amongst professionals to confirm that someone has a diagnosis of schizophrenia, manic depression or other allied illness. Perhaps they feel justified in this due to the perceived stigma that surrounds these terms. Or perhaps it is because mental illness is extremely difficult to diagnose accurately. Or possibly it is a combination of both.
But if we could see the diagnosis of these illnesses as the first step to treatment and hopefully the first leg on the road to recovery, as we would with diabetes, heart disease, or even cancer, there could be many benefits in terms of achieving effective individual care, reducing stigma, and overcoming fear that is often based on ignorance. For many service users and carers, a diagnosis brings great relief. By confirming what they have long suspected, the fear of the unknown is removed.
We cannot put enough emphasis on the importance of �early intervention� in mental health. This may mean that the label of �schizophrenia� or manic depression is given earlier. But without a diagnosis, no treatment and support can be accessed, and just occasionally in a very small percentage of cases, this will cause a crisis where a crime is committed.
This crisis may then involve a whole range of different labels being applied. If it is hard to accept that there is a diagnosis of �schizophrenia� and other mental illnesses, then it is doubly difficult to have added to that, the terms �mentally disordered offender�, �forensic patient�, �restricted patient�, �state hospital patient�, �secretary of state patient, although to be accurate i suspect this should now be �first minister�s patient�. And then there is the media who may in their way of sensationalising things, add to these, the term � �violent and dangerous criminal�. Now these really are labels.
So how can we avoid the crises from escalating? In many cases the family, carer or supporter is the first to recognise that their relative or friend is becoming ill. If we were dealing with a general illness like diabetes for instance, our first option would be to call the G. P. and hopefully he or she would then decide the best course of action. This may be to keep the patient at home, perhaps change or increase the medication, or admit them to the general hospital.
Care at home, or when discharged from hospital, could then be backed up by help from the community nurse, home help and other service providers. This system and support allows the patient time to recover and hopefully to cope and manage the illness, and their lives, even if it is debilitating in the short or long term.
Surely then, we should expect to access the same support for those with a mental illness? In the majority of cases this may be so. But unfortunately it is not always the case and the only option left to families who are trying to care for their mentally ill relative, who, due to the very nature of the illness, may be in an agitated and perhaps aggressive state, is to call the police. This surely cannot be right?
Carers do not want to call for police assistance. Having to do so can do immense and often irreparable damage to the very fragile relationship between the ill person and their carer. They want to be able to access the same 24 hours a day service, as those with general health problems and know that they will be listened to and taken seriously. This should be available whenever there has been prior contact with psychiatric services, diagnosis or no diagnosis. Service users also want to have that right to early intervention and to have that based on their need, not their age or any other criteria, and wherever possible, avoid coming into contact with the criminal justice system.
To make this possible we need to look at the options that are available, see where the problems are and try to plug the gaps in order to make a clear, uniform route that is available, nationally. Service users and their carers need to know exactly how to access appropriate help if they suspect that the situation is escalating to a potential crisis. For that to happen users and carers must be listened to, especially by those delivering front line services.
While there is clear intention from the majority of professionals to provide a first rate mental health service --- intention is of little use without commitment. This commitment has to come from all involved in providing care. G.P�s and psychiatric teams need to liaise and work together effectively to provide a truly integrated service.
Most relatives would like to be able to call their G.P. and know that he or she will give their situation as much priority as they would any other health emergency and respond accordingly.
Calling the police should be the very last option. Their knowledge of mental health is limited. They are there to combat and investigate crime, from motoring offences to murder. They are not mental health professionals and nor should we expect them to be. Nor should they be expected to pick up the pieces in these situations, unless all other avenues have been tried first.
Unfortunately, avoiding the involvement of the criminal justice system will not always be possible. It is a sad fact that increased drug and alcohol use, especially among the young, can exacerbate mental health problems. But in recognising that, it is even more vital for all involved in mental health, whether user, carer or provider, to know how to take avoiding action or our already overstretched systems of forensic psychiatry, criminal justice, and associated services will collapse under the weight of demand outstripping supply.
For those going through the mentally disordered offenders system, in secure hospitals, the road is long and hard. Often housed in institutions where security can exceed their needs and many miles from family and friends. With neither user nor carer given any idea as to how long the length of stay might be. Many of their basic rights as we know them are removed. For some, the crimes committed while ill and psychotic would be punished with a hefty fine or a period of community service in a �well� person. But where the crime is combined with a mental illness, society demands that the emphasis should be on public safety.
Of course, public safety is of paramount importance to us all. There will always be a need to have secure psychiatric facilities and high security prisons and there will be some people who will remain in these facilities for the rest of their lives. But these conditions should only be used at the period of most need to the patient and not because there is no alternative facility available to them when they are well enough to move on.
While acknowledging a responsibility towards public safety, we also have to acknowledge a responsibility towards individual need and a duty of care towards the more vulnerable groups in our society, however unpopular that group might be in the political arena.
Wherever possible, the emphasis of achieving effective individual care, should be on early intervention and prevention. While more specialist forensic services are being set up in the regions --- to provide continuity of professional care, there needs to be access to beds as near to the patients locale as possible. This too would allow both the statutory and voluntary sector services in terms of medical, housing and social care to work together at local level. And allow family relationships and friendships to be maintained wherever possible.
Continued care and support is surely an important part of rehabilitation allowing a more flexible approach to the differing needs of the individual. Whether this is managing the illness, lifestyle changes, enhancing skills and talents or further education or training. The family too could benefit from being part of this process, and by �caring� in the conventional sense, they may come to terms and start to rebuild their lives and the relationship with their relative.
Perhaps a more positive approach is needed to bridge the gap between physical and mental illness. True - there are differing needs where there is a mental health problem, but so too are there differing needs between those suffering from heart disease and those with cancer. By putting them into different categories we perpetuate stigma. By emphasising the word �mental� we fail to see that all patients, regardless of their illness, physical or mental, require the emphasis to be on general well being.
For those who have been in the secure system many miles from home, the sense of apprehension on returning to their own community is exacerbated by having to find their way round a whole new system and with a new set of professionals. Continued contact with services from the referring region would help to alleviate this and the feeling that they are �out of sight � out of mind�. We know that those with mental illness can benefit greatly from the support that they get from family and friends. By sending them to units miles from home, we punish them more by removing that support, increasing the sense of isolation and grief for both the service user and their family.
At present for too many patients this is the only option. There has to be a better way.
Carolyn Little, Mentally Disordered Offenders Conference 24th May 2002.
The content reflects personal opinion and is not necessarily that of any organization or group.
Ends.
Handout for the Conference:
Achieving Effective Individual Care
A Carer�s Perspective
As admirable a concept as �care in the community� is, it will never meet the needs of all the people, all of the time. But it could work well, most of the time�.
For that to happen, it needs to take a good, hard look at itself. Extra funding to recruit more highly specialist staff would go a long way to bringing it into line with general health, providing a round the clock service. That alone however, will not prevent the headline-making tragedies from occurring. Occasionally these tragedies could not have been foreseen and the outcome is unavoidable. For a handful of people suffering from mental health problems, the sad reality is that little if anything could have been done to prevent the outcome. What is not acceptable is when help has been requested, but it has not been provided.
General practitioners, psychiatrists, nurses and others, who come into contact with the mentally ill in their professional lives, owe it to themselves, and to society as a whole, to pull together and prevent the tragedies arising whenever possible. There are many hard working and dedicated professionals working in this field, whose early intervention will no doubt have prevented the escalation of such events.
But until this is standard practice right across the services, mistakes are admitted and learnt from, and they can communicate with each other and the public, tragic events will continue, bringing the whole ethos of �care in the community� into disrepute and disarray.
At the end of the day, the public wants an efficient and approachable service to aid them in their crisis. There is no room for apathy, inefficiency, arrogance or excuses in the health service.
Society deserves better. Those suffering from a mental illness deserve better. The whole culture of �care in the community� deserves better.
Extract from �Care in the Community� Article - Carolyn Little 2002.
The above extract is from an article written following the publication of a headline-making report. A mother had repeatedly tried to access medical help for her mentally ill son without success. The situation escalated. A tragedy occurred. A young family man was killed. Another young man was sent to the State Hospital.
The majority of people suffering from mental illness will never commit a crime.
However, when those caring for a mentally ill person, express concern that the situation is becoming critical � it is imperative that they are not only heard, but also listened to. Carers rarely call for help without just cause.
Carolyn Little, Mentally Disordered Offenders Conference, 24th May 2002.
POLICE
The police will be called upon in many cases where there is evidence of a mental health problem. It is vital therefore, that they receive appropriate training in recognising symptoms, and give �the benefit of the doubt� where they are uncertain � alerting mental health services in either case. That is, adopting the precautionary approach.
Where they have been called to a domestic situation regarding a mental health problem, they will need appropriate training to address the needs of all involved. Unfortunately, it is often in these situations, that the police feel that they have taken on the role of �social worker�.
LEGAL REPRESENTATION
A mentally ill person in need of legal representation following on from arrest has differing needs. The �duty solicitor�, may not have in depth knowledge of mental health law, thereby disadvantaging the mentally disordered offender further.
PLACE OF SAFETY
The lack of appropriate psychiatric facilities in some regions requires that prisons be used as a place of safety until alternative arrangements can be made.
YOUTH
When a crime is committed, a young person is sent to a Young Offenders Institution. When that young person also has a mental illness there are few specialist facilities to cater to the differing needs of this age group.
DISADVANTAGED
Mentally disordered offenders lose many rights. This includes the right to vote. Without a vote, they have no voice. Without a voice, they will be underrepresented. It is up to the rest of us in society to ensure that they are not further disadvantaged.
It is vital that we adopt a �proactive� approach to prevention � not �reactive�, by locking them up and throwing away the key.
Carolyn Little, Mentally Disordered Offenders Conference, 24th May 2002.
The content reflects personal opinion and is not necessarily that of any organization or group.
