Severe mental illness and dangerousness-part II

In the first part of this article, it was suggested that although at population level homicide committed by mentally ill people is relatively uncommon, that in a significant cohort of those with severe mental illness repeated poor management has led to tragic outcomes.

This picture has been consistent since the early eighties, highlighted in the Sharon Campbell Inquiry (1988) and replicated in the many cases since then (about 2505 cases of which only 1099 were subject to an independent inquiry). In the most recent case to attract public attention, committed by Valdo Calocane a diagnosed paranoid schizophrenic man, a triple stabbing homicide which also saw three others injured by a vehicle in Nottingham in June 2023, and which is currently the subject of a public inquiry, a similar pattern has emerged.

Many studies show mentally ill people who kill were not getting the care and treatment they needed. Many Mental Health Services are in denial about violence, are failing to investigate properly, failing to learn lessons, have a culture of secrecy and treat symptoms not causes. In addition, they often overlook the fact that psychotic patients often don’t think they’re ill, which is a key symptom of psychosis and differentiates it from neurotic disorders. They also closely guard patient confidentiality leading to failure to communicate with relatives and friends and treating their concerns with distain instead of listening to them and assessing with more vigour.

Mental health services are generally in denial about violence, many mental health practitioners and campaigners see violence as a taboo subject to the extent some deny it even exists. They do so out of an understandable but misguided fear of ‘stigmatising’ the mentally ill.

When an incident does happen, many mental health trusts are failing to investigate such cases properly. Some refuse to commission independent inquiries despite a clear requirement by the Department of Health to do so, instead relying on the internal self-investigatory reports.

It is also clear that mental health services are not learning lessons as analyses of many mental health homicide inquiries since 1993 show the same problems keep occurring.

These include a failure to keep proper records, failure to plan care properly, failure to do adequate risk assessments, failure to treat drug problems, failure to listen to families & carers, failure to follow up missed appointments, failure to ensure medication is taken, and a failure to assertively treat deteriorating patients.

A matter for public concern is the fact that these same problems crop up again and again in independent investigations despite being the subject of official national and professional guidance. It seems recommendations for change appear to be routinely ignored without sanction. Despite all the action plans and new policy initiatives there is little evidence that lessons are being effectively learned because the number of mental health homicides continues to rise.

The culture of secrecy cloaked in the myth of patient confidentiality leads to reluctance to share patient information with other agencies. This overriding concern for the rights of the patient over public safety can have severe consequences.

Finally, too many seriously ill psychotic patients are admitted to hospital when they are in crisis and released days or weeks later when medication appears to have stabilised their symptoms. Little attention is given to their long-term needs and issues or the concerns of relatives who will have to cope with them in the community.

The secret to tackling this well documented ‘sink hole’ in service provision is an overhaul of the legislation and treatment applied to specific patients. Confidentiality should be able to be overridden in certain cases to allow fuller assessment and monitoring and in order to engage relatives, friends and others who provide community support, such as landlords, employers and other agencies.

The traditional community mental health approach of outpatient care and community mental health teams with large caseloads does not work. One model which has been seen to be more effective is Assertive Outreach, or Assertive Community Treatment. This was introduced in the nineties following the Clunis and Silcock cases but because it did not conform to the dominant medical model of care it was undermined and denied by academics and practitioners in the UK.

However Assertive Outreach is still the treatment of choice for the severely mentally ill who are difficult to engage in the community. It involves taking services to the patients rather than requiring them to attend appointments, hospitals and clinics. The model is one of a high staff-to-patient ratio offering comprehensive health and social care. It results in reduced hospitalizations, promotes effective engagement with difficult patients and improves patient wellbeing. In addition, it supports engagement with families and the community around the patient, thus providing a better chance that support will not break down so readily.

Therefore, on a prima facie case and supported by years of research, it still has relevance in order to tackle this problem for a select group of severely mentally ill people, one that has eluded the mental health system for decades. It will only be fully effective though if legislation in respect to confidentiality is modified and mental health law is tightened to ensure a duty of co-operation between agencies in such cases.

Sources:

• Report of the Committee of Inquiry into the Care and After-Care of Miss Sharon Campbell, (1988) Department of Health and Social Security, The Stationary Office, London.
• The Nottingham Inquiry – A public inquiry into the devastating Nottingham attacks in June 2023.
• https://www.hundredfamilies.org/
• Burns and Firn (2002) Assertive Outreach in Mental Health: A manual for practitioners, Oxford University Press.
• Hamilton, Lloyd, Bland, Savage and Grainge (2015) The impact of assertive outreach teams on hospital admissions for psychosis: a time series analysis, Journal of Psychiatric and Mental Health Nursing, Volume 22, Issue 7 pp. 484-490.