Bad cases, research and reviews The perilous progress of forensic psychiatry. Pamela J Taylor. Bad case? when one person with a mental disorder seriously harms others when such a case stigmatises others with mental disorder when psychiatrists/mh workers are defined by a single case
Pamela J Taylor
1st January 1843 Daniel McNaughton mortally wounded Edward Drummond
19th June 1843 House of Lords: The McNaughton Rules
Dropped out of school; disowned by father
Co-workers descn :quiet & unremarkable, but a bit of a loner
After one month in treatment judged "capable of taking care of himself"
in and out of hospital 1999.
kicked out of several apartments e.g. for throwing his garbage from the balcony 2000
On May 23 2001, again committed to mental hospital, but left after one day; did not return.
‘institutionalized even more often than he had been arrested’
On June 8th 2001, court case pending, took OD, ran amok in
Wrestled down by staff within minutes; described as being in an extremely confused state when arrested
Later, on interrogation he stated:
Anything and everything has become unbearable. Time and time again I tried kill myself but I could not do it. I wanted to be arrested and get the death sentence
Takuma was hanged barely three years after the attacks
The imperfection of the law has become clear and certain changes to Japan’s psychiatric system should be considered for mentally ill offenders
Law Concerning Medical Treatment and Observation for People Who Commit Serious Harm to Others Under the Condition of Lost Mind and the Like 2003
FORENSIC PSYCHIATRIC SERVICE SYSTEM IN JAPAN
FORENSIC SECURE UNITS
APPEAL FOR DISCHARGE
GENERAL MENTAL HOSPITAL
FORENSIC OUTPATIENT SERVICES
ABSOLUTE DISCHARGE OR ADMISSION UNDER GENERAL MENTAL HEALTH LAW
EXAMINATION OF LOST MIND
EXAMINATION OF TREATABILITYAND RISK
COMMUNITY MENTAL HEALTH CENTRE OR OTHER COMMUNITY CARE FACILITIES
Several years of m. illness
13 voluntary hospitalisations in 2+ years
3,500 pps of casenotes
15th December 1998
‘ought to have an intensive case manager’
disorganised, unable to manage his money, care for himself and becomes non-compliant with meds
talking to himself
Had attacked at least 13 people including health care staff in the period
Bedlam on the Streets
Maybe they should have just stenciled it in large letters on AG’s forehead:
Ticking time bomb, suffers schizophrenia, if off medication, run for cover!
December 26th 1998
had missed 2 OP dates
Clinic worker wrote to him that if he hadn’t called by January 6th 1999 his case would be closed
January 3rd 1999 pushed Kendra Webdale to her death under a subway train
Trial no.1 hung jury
Trial no 2. convicted of second degree murder and sentenced to 25years-life
Trial no 3. pending, plea bargain guilty as before, 23 years + five years supervision and psychiatric supervision.
The Assisted Outpatient Treatment Program
mentally ill people who are capable of living in the community with the help of family, friends and mental health professionals, but who, without routine care and treatment, may
relapse and become violent or suicidal, or require hospitalization.
Lin & Megan
& Josie Russell
Alan Beith, MP
Jack Straw, MP. Hansard 26th October 2000
South East Coast Strategic HA, Kent County Council, Kent Probation Area commissioned independent report, 30th November 2000, published October 2006
Imprisonment for public protection
Indefinite sentences for a convicted person considered to be dangerous to the public
Usually given a tariff, but must complete courses and show change
Government prediction of need: 900 places
The reality: 4,800 in July 2008
New projection 12,000 by 2014
Higher rates of mental disorder than other prisoners:
1/5 in previous treatment
1/5 on medications
The Mental Health Act 2007
Mental disorder means any disorder or disability of mind
Promiscuity or other immoral conduct, and sexual deviance no longer excluded
Suffering from a mental disorder of a nature or degree …
Appropriate medical treatment (AMT) is available
AMT is that medical treatment which is appropriate the case, taking into account the nature and degree of the mental disorder and all other circumstances of the caseNew Laws
b. 18th May 1963
Good school record
Mother ill 1980, left UK; d.1985
1986 ‘rambling’; ‘odd behaviour’; first violence; left UK; 1st mh admission
1987 returned to UK; June:schizophrenia
January 1988: ‘drug induced psychosis’ or ‘manipulation for a bed’
1988-92 many assessments/admissions for schizophrenia and threatening behaviour/violence
Saw 43 different psychiatrists in this period
14th August paranoid schizophrenia
10th September: normal mental state, abnormal personality
1st December: SW - ‘nothing untoward in attitude or behaviour’
10th December: failed outpatient appointment
17th December: killed Jonathan Zito
17th December: FME diagnosed ‘psychotic personality disorder’
18th December: psychiatrist - ’psychotic unfit for interview’
22nd December: fp - psychotic needs urgent transfer to hospitalBut, as elsewhere, most of our single, driving cases are of schizophrenia too
Requiring full independent inquiry into a homicide committed by someone previously in contact with mental health services.
The Guidance led to nearly 300 independent inquiries up to June 2005
Limitations of the system and challenges to it
Munro & Rumgay 2000, BJPsy
40 reports 1988-1997
11 (27.5%) predictable
26 (65%) preventableConstructive outcomes?The Zito Trust & Some knowledge generation
Consecutive series of cases since April 1996 drawn from the [Home Office] Homicide Index
Psychiatric reports for court when available (49%) [R v Reid]
Previous offending data from the National Crime Operations Faculty
Cases submitted to mh services in area of last residence for each case
Where service contact identified, questionnaire sent to consultant psychiatrist
April 1999-Dec 2003
Total n 2684
Life time history of any mental disorder
Life time schizophrenia
Life time contact with mh services
Contact with services in the last 12 months
41 21% any diagnosis
23 56% with schizophrenia
7 per yearThe National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
a multi-centre ethics committee (MREC) under the
National Health Service (NHS) Central Office for
Research Ethics Committees (COREC), which -
e.g. for one five site project 11 separate applications:
40% of all clinical academics NHS funded selected causes of death
Annual Department of Health spend on NHS research £680m
Other government department annual spend on NHS research £180m
Research Councils £440m
HE funding Councils paid directly to medical schools £400m
100% forensic mental health clinical academics NHS funded
Annual Department of Health spend on fmh research £1.3m
Other government department spend on fmh research c. £2m
Research Councils negligible
No medical School funding for fmh research
No dedicated charityA UK funding crisis for forensic mental health research
Best Research for Best Health (consultation)
www.dh.gov.ukkStrategic Analysis of UK
Mental Health Research Funding
* directly: Lehman & Linn ’84, Mueser et al ’98, Walsh et al 2003
* indirectly: 1. neighbourhood of residence Silver 2000, Logdberg, 2004
2. press/public fear/hostility Ward 1997
Accumulating knowledge multi-directional
Since 1990, sound c.s. epidemiological studies on frequency of violence-mental illness association
Some longitudinal data; growing attention to pathway studies
Basic understanding of illness mechanisms
‘black box’ outcome studies
Management framework studies
Subgroup specific studies:
* specified ethnic
Complex treatment studies
Allowance for regional and international differencesBut, in spite of the difficulties, facts are accumulating and there is greater awareness of real gaps in knowledge
4 European studies; violence 4-7 X general population
A cross-sectional US based
household surveySwanson et al, 1990
Wallace et al, 1998
Proportion of disorder & violence association independently accounted for by selected explanatory variablesArseneault, Moffitt, Caspi, Taylor, Silva, 2000
Categorised such that groups are mutually exclusive
Cannabis group: 30/36 used cannabis only; 6 also had alcohol use diagnosis
Other/mixed drug group: 32/53 diagnosed with multiple drug use disorder; 2 used multiple drugs and alcohol, others single illicit drug use disorders
Alcohol use disorder Χ2=6.47, p <.05
Cannabis use disorder Χ2=44.2, p <.001
Other / mixed drug use disorder Χ2=13.1, p <.001
PD + psychosis
15% in the month prior, most choosing alcohol
9% in the final 24 hours, again most misusing alcohol
Substance use is significantly less prevalent in those driven to the IO by psychotic symptoms …
… perhaps psychosis and substance use provide separate explanations for dangerousness?
Delusions VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)
A belief - acceptance of proposition without evidence
A ‘normal delusion’: belief held to be false because held by a political, cultural or religious opponent
A ‘psychotic delusion’: Absolute conviction of the truth of a proposition which is idiosyncratic, incorrigible, ego-involved and often preoccupying’
Kraupl Taylor, 1979
Bell et al, 2006
Feeling that one’s mind is dominated by forces beyond one’s control
Feeling that thoughts are being put into one’s mind that are not one’s own
Feeling that there are people who wish to do one harm
From Psychiatric Epidemiologic Research Interview Dohrenwend et el, 1980Delusions and threat/control-override symptoms
Why be concerned about social context? VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)relationship of perpetrator to victim & seriousness of index offence (n=975) Johnston & Taylor, 2003
Nordström & Kullgren, 2003
2. ‘imperviousness to other experiences and to compelling counter-argument’
3. ‘their content is impossible’. Jaspers, 1913
‘… unresponsive to the presentation of evidence contrary to the belief’ Oltmanns, 1988
BELIEF ***** MAINTENANCE talking about them depends on giving up a belief about these beliefs
seeking support for belief
adjusting belief on contradiction
being frightened by it
Action (+ve act)
InsightMaudsley Assessment of Delusions Schedule (MADS) Taylor et al. 1994
ACTORS belief ……
Ignores 9 (39)
Accommodates 1 ( 4)
Changes convic’n 12 (52)
Dismisses delusion 1 ( 4)
3 ( 5)
X23=15.77 P<0.002Hypothetical challenge and action on delusions
recipient establishing links between thoughts, feelings and actions wrt target symptoms
correction of misperceptions, irrational beliefs & reasoning biases
recipient monitoring behaviours and/or promotion of alternative ways of coping
RCTs for schizophrenia/schiz. like illnesses: 30 papers, 19 trials
2154 subjects, of whom 925 had CBT according to the definition*
Compared to standard care -reduced risk of staying in hospital (1x62); improved medium term mental state (2RCTs, n=123), but no consistent effect; no effect on relapse/ readmission (4RCTs, n=357)
Compared to supportive psychotherapy or psycho-educational approaches, no effect.
No study measured adverse effects, whether on the study participants or on those giving the treatment (or on anyone else outside the treatment circle)
Why should this matter in studying psychosis and violence?
Duffet et al, 1998
Delal et al, 1999
Swinton et al, 2000
Sex: 224 men 54 women n.s.
Ethnic group: 93 A/C 185 W/I n.s.
Admission age (med.) 32 m (24-79) 26 w (23-55) n.s.
Pure psychosis/+pd 224 54 n.s.
Index offence: homicide 71 n.s.
non-fatal violence 153 n.s.
sexual 18 n.s.
CD/fire 21 n.s.
Seriousness of phys.harm n.s.
Restricted cases 184 n.s.
There is a long history of such reviews
e.g. Reports from Select Committees on Criminal and Pauper Lunatics & on the Better Regulation of Madhouses in England 1807-16
There are often several pertinent reviews happening simultaneously
e.g. general service reviews, specific service reviews, an individual homicide inquiry
Response to notification of a review is extensive
e.g. The Corston Report on ‘women with particular vulnerabilities in the criminal justice system’ received c. 250 individual submissions: 11 from families, c. 60 from individuals & the rest from organisations.
Major reviews, particularly government sponsored reviews, do have some impact
e.g. 1992 Dept Health & Home Office review for England recommended decrease in high security beds and increase in medium security beds - done
Medium & low security
..even in New Zealand
Effect on service users?
What before and after change studies? ………NONE
What outcome studies?
Re-offending; re-admission; mortality
but, rarely take account of confounding variables –
even time at risk
What studies measuring change over time? …..ONE?
in admission/discharge cohorts?
in other outcomes? e.g. better service user experiences/health?
Effect for wider public? ……………NONE?
Why so little?
How can forensic services integrate more effectively within a mental health whole system?
How can inter/intra agency collaboration be improved?
How can treatment options, patient safety and proximity to family and home services be improved ?
How can patient flow be improved within the whole system retaining safe and effective service provision and public confidence?
How can more efficient and controlled use be made of secure service expenditure?
Full engagement of all interested parties across the professional, service user and carer and wider community constituencies
gain support for the review process
fully inform maintenance and change
build ownership for emerging improvements
Methods used included
workshops, seminars and conferences
literature review, acknowledging the evidence base
regular briefings for frontline staff, their leaders and other opinion formers
** New resources for research are essential
** Better understanding of the special ethical & practical
issues raised by the field also important