Brit.J.
Psychiat. (1978), 133,448—51
A Psychiatric Clinic in a Probation
Office
By PAUL BOWDEN SUMMARY
A weekly
clinic
was
held
for
one
year
in
a London
probation office with 41 probation officers. Only 23 cases were referred but the clinic was found to be a valuable forum for discussion of prob lems with the officers, 10 per cent of whose clients were estimated to be receiving psychiatric treatment elsewhere. Suggestions are made to improve collaboration between psychiatrists and probation officers. Introduction A weekly psychiatric clinic was established in a probation office for an experimental period of one year. Its purpose was to assess the clients of probation officers who refused to accept the need for referral to a psychiatric hospital, and also those who were too socially disorganized to keep out-patient appointments. It was hoped that the psychiatrist involved with the clinic would be identified with the probation service rather than a particular hospital. Previous experience was that the main source of referrals to a forensic out-patient clinic was from the probation service, and Bluglass (1976) reported similar findings. However, more than a third of these referrals failed to attend and for those who did it was often difficult to establish a commitment to regular treatment. Furthermore, referral letters, extensive social enquiry reports, casework
notes and previous
psychiatric
reports
indicated that many non-attenders had major psychiatric illnesses associated with behaviour disorder. The view that these patients represent an important but neglected group is supported by Whyte (1975) in his study at a general psychiatric clinic. He compared new patients with a group who did not attend: non-attenders were less stable socially, had more convictions, more extensive histories of previous psychiatric treatment and they were more likely to have deteriorated since referral to the clinic. To emphasize that the clinic was to cater for individuals who would not normally receive treatment, several restrictions were put on
referral: their
ex-patients
previous
should be referred back to
psychiatrist;
cases
which
were
newly identified by probation officers as requiring psychiatric assessment should follow the usual referral channels to other hospital clinics. Informal co-operation between psychiatrists and probation officers existed before the passing of the 1948 Criminal Justice Act which allowed for psychiatric treatment as a condition of a probation order. That Act was recently con solidated in Section 3, Powers of Criminal Courts Act, 1973. Closer liaison between those responsible for the supervision and rehabilita tion of patients subject to special restrictions under Part V of the Mental Health Act, 1959 was recommended by the Aarvold Committee, 1973. More specifically the Interim Report of the Butler Committee, 1974, referred to the value of regional secure hospital units as reference points for the probation and after-care service, although the Committee finally rejected a recommendation from the chief probation officers that there should be part-time psychiatric consultants to the probation service, on the grounds that there were too few psychiatrists with sufficient experience in dealing with offenders. Method The clinic was held at a probation office in South-East London; the same building contains a Magistrates' Court. The 41 probation officers had ready access to forensic clinics at the
448
449
PAUL BOWDEN
Maudsley
Hospital
and the psychiatric
ments of three nearby
teaching
office was also the base for probation
Reaction
depart
hospitals.
The
officers at a
second Magistrates' Court, a Crown Court and a Day Training Centre. The purpose of the clinic was discussed with probation officers who were asked to refer clients, subject to the guidelines mentioned
earlier.
It was hoped
that
patients
would only be referred elsewhere from this experimental clinic if they required services which could not be provided, e.g. in-patient treatment. Findings officers assessed 10 per cent of their
Probation clients
as currently
ment.
Because
vising
clients
Training support,
receiving
psychiatric
treat
some officers were not super and
Centre,
others,
had
e.g.
their
at
the
Day
own psychiatric
only 32 were in a position
where
they
were likely to refer cases. In fact 17 officers made referrals; two officers referred 3 clients and two officers referred2. It was possible to separate the
referrals
into
5 categories
depending
on
outcome. 1. Never attended 1. A homosexual drug addict with seriously antisocial behaviour. Currently in con tact with psychiatric services and other organizations.
2. A recidivist with chronic anxiety recurrent severe depressive illnesses. 3.
Antisocial
behaviour
in the child
and of an
immigrant family. 4. A known paranoid schizophrenic, often violent but untreatable on a voluntary basis.
They failed to keep the several appointments which they separately received although pro bation officers made considerable efforts to ensure their attendance. This failure rate was lower than it had been at the hospital-based clinic, but again those who did not attend appeared to have evidence of quite severe
disability
associated
behavioural
with
mental
illness and
disorder.
2. Attended once 5.
Severe
with
maladjustment
persistent
anxiety
in an individual
and
phobias.
formation
powerful
and brave.
as
outrageously
Pathological
liar.
6. An agitated and paranoid person whose history gested
and
mental
state
schizophrenia.
strongly
sug
Too unco-operative
and hostile to assess fully.
7. Phobic and obese heavy drinker. Depen dent on elderly parents. Extremely aggressive. Here was good evidence of mental disorder to account for aggressiveness which also precluded attendance at the clinic. Although these cases refused to be seen after the initial
assessment it was possible to give some inform ation to the supervising probation officer. Overallthosewho didnotattendand thosewho came to the clinic on one occasion only appeared tobe particularly disordered. 3. Management tissessment 8. Dependent woman struggling to live with unfaithful, chauvinist spouse. Re ferred to prisoners' families organiza tion. 9. Elderly pederast, impotent and alibi dinous following prostatectomy. Advised on after-care whileon parole. 10.
Young
person
with
considerable
experi
ence of psychotherapy. Abused psycho tropic drugs; self-help encouraged with superficial
11. Parents &
support.
seen
because
with
probation
of assaultative
threats
officer to child
12. and deteriorating marital situation. Ad vised on the assessment of seriousness of risk.
13. Immature
and dependent
person
seen
following a bizarre sexual assault on younger sibling. Supported through court trial and separation
14.
from family.
Anti-authoritarian young person with strong family history of violence. In volved in cycle of provocation—violence —¿retribution.
15. No psychological disorder found in an expert recidivist shoplifter. 16. An hysteric who abused both psycho tropic agents and advice. Existing contact with
four
social
further involvement.
agencies
precluded
450
A PSYCHIATRIC
CLINIC
IN A PROBATION
OFFICE
17. Demanding hysteric whose chaotic exist ence made planned management im possible. Advised on crisis intervention. It was more appropriate for these cases to be referred elsewhere, or clients were already
sought an assurance that it would responsible for the care of patients
receiving
a psychiatrist and others were concerned with aspects of confidentiality. The referral rate was not adequate to justify a weekly clinic, but a less frequent commitment could probably have been maintained. The officers had access to
adequate
help from other
agencies.
other manipulative individuals it was best to limit their contact to one person, the supervising probation officer. This were not managed in the long-term by iatrists
although
a psychological
In
though usually group psych
contribution
to
their overall care was valued. 4.
Adolescent arsonist, later brain-damaged. Heavy drinking and morbid jealousy with severe depressive episodes.
19. Heavy
drinking
with warden led to further
recidivist.
of probation stress.
Cohabited hostel
which
Case receive
18 had previously been unwilling psychiatric help and, although
attended
the clinic regularly
to he
whilst on probation,
he failed when his probation order expired. The second person required some support during a stressful period when he set up home with the warden of his probation hostel. 5.
Referred to other psychi atric services
20.
Long-lasting phobic anxiety state in a person previously dependent on mor phine derivatives and alcohol. Referred to local psychiatrist for treatment of depression. 21. Psychostimulant dependency; referred to
22.
the clinic. Some probation officers expressed the view that their professional status might be compromised
many
other
centres
Managed at clinic 18.
local psychiatric services. Socially unstable heavy drinker
who had
achieved considerable notoriety. Aggres sive and seif-mutilatory in probation hostel. Admitted to psychiatric unit. 23. Schizophrenia diagnosed for first time in a young man. Originally placed on a probation order as a result of assaultative behaviour which was, in retrospect,
not be held taken on at
by such close collaboration
psychiatrists
and although
at
several
with
different
it was not intended
to
divert clients from existing patterns of referral the operational guidelines were probably too restrictive. In the clinic's latter months it came to be used by probation officers as a forum for
discussion of their clients' management. developments
probably
reflected
the
These needs
of
officers who valued a different formulation of a case, the opportunity to discuss alternative
approaches
to management,
importance
of psychological
and advice on the symptoms.
They
welcomed the opportunity to discuss their own relationships with their clients with someone who was not part of the probation hierarchy. It is likely that three individuals (cases 5—7) would not have been seen elsewhere, at least voluntarily, but unfortunately the only value of referral was that a superficial assessment of their mental
state,
and
its relation
to their
predica
ment, was made. The two persons taken on for treatment would probably not have been seen at an outside clinic: case 18 would not have accepted referral and case 19 was involved in an internal probationary problem which needed to be dealt with by the service. In the cases of clients 22 and 23 the clinic probably facilitated earlier referral to hospital. Group 3 (management assessment) was interesting because the need for advice in such cases had not been foreseen. Far from represent ing a group of difficult would-be patients these individuals
were
not
sent
elsewhere
because
they were threshold cases in which officers delusionally motivated. Admitted to required advice as to whether or not they were hospital fortreatmentand rehabilitation. suitable cases for referral. The relatively large numbers
Discussion Both agencies involved in the project approached it cautiously. My own hospital
in this group
consultancy probation
There
suggests
that
there
role open to psychiatrists
is a
in the
field.
is evidence
that existing co-operation
451
PAUL BOWDEN
between
probation
ineffective
and
remand offenders
officers and psychiatrists
is in need
setting
many
be made
of review.
recommendations
subject
to a probation
a
that order
with the condition that they receive psychiatric treatment are not accepted by courts (Sparks, 1966) because the necessary collaboration has not taken place between the agencies involved, or the patient may refuse treatment to which he had previously consented (Bowden, 1978). Woodside
(1976)
showed
that,
of the
small
numbers who actually present for treatment, many default early in their careers as out patients. The inadequate liaison between the professions could be remedied if psychiatrists provided a consultancy service to probation officers
as
was
recommended
by
the
Acknowledgements
is
From
chief
probation officers to the Butler Committee. Such a minimum expenditure of psychiatric resources could increase the effectiveness of the service which probation officers and psych iatrists provide for mentally disordered offenders.
This project could not have been undertaken the support Officer.
of Peter
McNeal,
Assistant
Chief
without Probation
References
A@utvow Coswrrrv2 Procedures
for
(1973) Report on the Review of the
Discharge
and
Supervision
of
Psychiatric Patients Subject to Special Restrictions. Home Office and DHSS. London: HMSO. BLUGLASS, R.
(1976)
community.
Forensic
psychiatric
services
in the
Journal of the Irish Medical Association, 68,
454—9. BownEN,
P. (1978)
Men
remanded
for medical
the outcome of the treatment
reports:
recommendation.
British Journal of Psychiatry, 133,000-00. BuTtaa Coswirraz (1974) Interim Report
of the Com
mittee on Mentally Abnormal Offenders. Home Office and DHSS. London: HMSO. —¿
(1975)
Abnormal
Report
of
Offenders.
the
Committee
Home
on
Office and
Mentally
DHSS.
London: HMSO. Spduucs, R. (1966) The decision to remand for mental examination. British Journal of Criminology,6,6-26. WIrrrE, R. (1975) Psychiatry new-patient clinic non
attenders. BritishJournal of Psychiatry,127,160-2. WoonsmE, M. (1976) Psychiatric referrals from Edinburgh Courts. British Journal of Criminology, 16,20-37.
Paul Bowden, M.Phil.,M.R.C.P.,M.R.C.Psych., Consultant Forensic Psychiatrist, South West Thames Regional Health Authority;
Hon. Senior Lecturer in Psychiafty, St George's Hospital, SWJ7
(Received 28 November 1977; revised 31 March 1978)
A psychiatric clinic in a probation office. P Bowden BJP 1978, 133:448-451. Access the most recent version at DOI: 10.1192/bjp.133.5.448
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/133/5/448#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;133/5/448 http://bjp.rcpsych.org/ on October 3, 2016 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
Psychiat. (1978), 133,448—51
A Psychiatric Clinic in a Probation
Office
By PAUL BOWDEN SUMMARY
A weekly
clinic
was
held
for
one
year
in
a London
probation office with 41 probation officers. Only 23 cases were referred but the clinic was found to be a valuable forum for discussion of prob lems with the officers, 10 per cent of whose clients were estimated to be receiving psychiatric treatment elsewhere. Suggestions are made to improve collaboration between psychiatrists and probation officers. Introduction A weekly psychiatric clinic was established in a probation office for an experimental period of one year. Its purpose was to assess the clients of probation officers who refused to accept the need for referral to a psychiatric hospital, and also those who were too socially disorganized to keep out-patient appointments. It was hoped that the psychiatrist involved with the clinic would be identified with the probation service rather than a particular hospital. Previous experience was that the main source of referrals to a forensic out-patient clinic was from the probation service, and Bluglass (1976) reported similar findings. However, more than a third of these referrals failed to attend and for those who did it was often difficult to establish a commitment to regular treatment. Furthermore, referral letters, extensive social enquiry reports, casework
notes and previous
psychiatric
reports
indicated that many non-attenders had major psychiatric illnesses associated with behaviour disorder. The view that these patients represent an important but neglected group is supported by Whyte (1975) in his study at a general psychiatric clinic. He compared new patients with a group who did not attend: non-attenders were less stable socially, had more convictions, more extensive histories of previous psychiatric treatment and they were more likely to have deteriorated since referral to the clinic. To emphasize that the clinic was to cater for individuals who would not normally receive treatment, several restrictions were put on
referral: their
ex-patients
previous
should be referred back to
psychiatrist;
cases
which
were
newly identified by probation officers as requiring psychiatric assessment should follow the usual referral channels to other hospital clinics. Informal co-operation between psychiatrists and probation officers existed before the passing of the 1948 Criminal Justice Act which allowed for psychiatric treatment as a condition of a probation order. That Act was recently con solidated in Section 3, Powers of Criminal Courts Act, 1973. Closer liaison between those responsible for the supervision and rehabilita tion of patients subject to special restrictions under Part V of the Mental Health Act, 1959 was recommended by the Aarvold Committee, 1973. More specifically the Interim Report of the Butler Committee, 1974, referred to the value of regional secure hospital units as reference points for the probation and after-care service, although the Committee finally rejected a recommendation from the chief probation officers that there should be part-time psychiatric consultants to the probation service, on the grounds that there were too few psychiatrists with sufficient experience in dealing with offenders. Method The clinic was held at a probation office in South-East London; the same building contains a Magistrates' Court. The 41 probation officers had ready access to forensic clinics at the
448
449
PAUL BOWDEN
Maudsley
Hospital
and the psychiatric
ments of three nearby
teaching
office was also the base for probation
Reaction
depart
hospitals.
The
officers at a
second Magistrates' Court, a Crown Court and a Day Training Centre. The purpose of the clinic was discussed with probation officers who were asked to refer clients, subject to the guidelines mentioned
earlier.
It was hoped
that
patients
would only be referred elsewhere from this experimental clinic if they required services which could not be provided, e.g. in-patient treatment. Findings officers assessed 10 per cent of their
Probation clients
as currently
ment.
Because
vising
clients
Training support,
receiving
psychiatric
treat
some officers were not super and
Centre,
others,
had
e.g.
their
at
the
Day
own psychiatric
only 32 were in a position
where
they
were likely to refer cases. In fact 17 officers made referrals; two officers referred 3 clients and two officers referred2. It was possible to separate the
referrals
into
5 categories
depending
on
outcome. 1. Never attended 1. A homosexual drug addict with seriously antisocial behaviour. Currently in con tact with psychiatric services and other organizations.
2. A recidivist with chronic anxiety recurrent severe depressive illnesses. 3.
Antisocial
behaviour
in the child
and of an
immigrant family. 4. A known paranoid schizophrenic, often violent but untreatable on a voluntary basis.
They failed to keep the several appointments which they separately received although pro bation officers made considerable efforts to ensure their attendance. This failure rate was lower than it had been at the hospital-based clinic, but again those who did not attend appeared to have evidence of quite severe
disability
associated
behavioural
with
mental
illness and
disorder.
2. Attended once 5.
Severe
with
maladjustment
persistent
anxiety
in an individual
and
phobias.
formation
powerful
and brave.
as
outrageously
Pathological
liar.
6. An agitated and paranoid person whose history gested
and
mental
state
schizophrenia.
strongly
sug
Too unco-operative
and hostile to assess fully.
7. Phobic and obese heavy drinker. Depen dent on elderly parents. Extremely aggressive. Here was good evidence of mental disorder to account for aggressiveness which also precluded attendance at the clinic. Although these cases refused to be seen after the initial
assessment it was possible to give some inform ation to the supervising probation officer. Overallthosewho didnotattendand thosewho came to the clinic on one occasion only appeared tobe particularly disordered. 3. Management tissessment 8. Dependent woman struggling to live with unfaithful, chauvinist spouse. Re ferred to prisoners' families organiza tion. 9. Elderly pederast, impotent and alibi dinous following prostatectomy. Advised on after-care whileon parole. 10.
Young
person
with
considerable
experi
ence of psychotherapy. Abused psycho tropic drugs; self-help encouraged with superficial
11. Parents &
support.
seen
because
with
probation
of assaultative
threats
officer to child
12. and deteriorating marital situation. Ad vised on the assessment of seriousness of risk.
13. Immature
and dependent
person
seen
following a bizarre sexual assault on younger sibling. Supported through court trial and separation
14.
from family.
Anti-authoritarian young person with strong family history of violence. In volved in cycle of provocation—violence —¿retribution.
15. No psychological disorder found in an expert recidivist shoplifter. 16. An hysteric who abused both psycho tropic agents and advice. Existing contact with
four
social
further involvement.
agencies
precluded
450
A PSYCHIATRIC
CLINIC
IN A PROBATION
OFFICE
17. Demanding hysteric whose chaotic exist ence made planned management im possible. Advised on crisis intervention. It was more appropriate for these cases to be referred elsewhere, or clients were already
sought an assurance that it would responsible for the care of patients
receiving
a psychiatrist and others were concerned with aspects of confidentiality. The referral rate was not adequate to justify a weekly clinic, but a less frequent commitment could probably have been maintained. The officers had access to
adequate
help from other
agencies.
other manipulative individuals it was best to limit their contact to one person, the supervising probation officer. This were not managed in the long-term by iatrists
although
a psychological
In
though usually group psych
contribution
to
their overall care was valued. 4.
Adolescent arsonist, later brain-damaged. Heavy drinking and morbid jealousy with severe depressive episodes.
19. Heavy
drinking
with warden led to further
recidivist.
of probation stress.
Cohabited hostel
which
Case receive
18 had previously been unwilling psychiatric help and, although
attended
the clinic regularly
to he
whilst on probation,
he failed when his probation order expired. The second person required some support during a stressful period when he set up home with the warden of his probation hostel. 5.
Referred to other psychi atric services
20.
Long-lasting phobic anxiety state in a person previously dependent on mor phine derivatives and alcohol. Referred to local psychiatrist for treatment of depression. 21. Psychostimulant dependency; referred to
22.
the clinic. Some probation officers expressed the view that their professional status might be compromised
many
other
centres
Managed at clinic 18.
local psychiatric services. Socially unstable heavy drinker
who had
achieved considerable notoriety. Aggres sive and seif-mutilatory in probation hostel. Admitted to psychiatric unit. 23. Schizophrenia diagnosed for first time in a young man. Originally placed on a probation order as a result of assaultative behaviour which was, in retrospect,
not be held taken on at
by such close collaboration
psychiatrists
and although
at
several
with
different
it was not intended
to
divert clients from existing patterns of referral the operational guidelines were probably too restrictive. In the clinic's latter months it came to be used by probation officers as a forum for
discussion of their clients' management. developments
probably
reflected
the
These needs
of
officers who valued a different formulation of a case, the opportunity to discuss alternative
approaches
to management,
importance
of psychological
and advice on the symptoms.
They
welcomed the opportunity to discuss their own relationships with their clients with someone who was not part of the probation hierarchy. It is likely that three individuals (cases 5—7) would not have been seen elsewhere, at least voluntarily, but unfortunately the only value of referral was that a superficial assessment of their mental
state,
and
its relation
to their
predica
ment, was made. The two persons taken on for treatment would probably not have been seen at an outside clinic: case 18 would not have accepted referral and case 19 was involved in an internal probationary problem which needed to be dealt with by the service. In the cases of clients 22 and 23 the clinic probably facilitated earlier referral to hospital. Group 3 (management assessment) was interesting because the need for advice in such cases had not been foreseen. Far from represent ing a group of difficult would-be patients these individuals
were
not
sent
elsewhere
because
they were threshold cases in which officers delusionally motivated. Admitted to required advice as to whether or not they were hospital fortreatmentand rehabilitation. suitable cases for referral. The relatively large numbers
Discussion Both agencies involved in the project approached it cautiously. My own hospital
in this group
consultancy probation
There
suggests
that
there
role open to psychiatrists
is a
in the
field.
is evidence
that existing co-operation
451
PAUL BOWDEN
between
probation
ineffective
and
remand offenders
officers and psychiatrists
is in need
setting
many
be made
of review.
recommendations
subject
to a probation
a
that order
with the condition that they receive psychiatric treatment are not accepted by courts (Sparks, 1966) because the necessary collaboration has not taken place between the agencies involved, or the patient may refuse treatment to which he had previously consented (Bowden, 1978). Woodside
(1976)
showed
that,
of the
small
numbers who actually present for treatment, many default early in their careers as out patients. The inadequate liaison between the professions could be remedied if psychiatrists provided a consultancy service to probation officers
as
was
recommended
by
the
Acknowledgements
is
From
chief
probation officers to the Butler Committee. Such a minimum expenditure of psychiatric resources could increase the effectiveness of the service which probation officers and psych iatrists provide for mentally disordered offenders.
This project could not have been undertaken the support Officer.
of Peter
McNeal,
Assistant
Chief
without Probation
References
A@utvow Coswrrrv2 Procedures
for
(1973) Report on the Review of the
Discharge
and
Supervision
of
Psychiatric Patients Subject to Special Restrictions. Home Office and DHSS. London: HMSO. BLUGLASS, R.
(1976)
community.
Forensic
psychiatric
services
in the
Journal of the Irish Medical Association, 68,
454—9. BownEN,
P. (1978)
Men
remanded
for medical
the outcome of the treatment
reports:
recommendation.
British Journal of Psychiatry, 133,000-00. BuTtaa Coswirraz (1974) Interim Report
of the Com
mittee on Mentally Abnormal Offenders. Home Office and DHSS. London: HMSO. —¿
(1975)
Abnormal
Report
of
Offenders.
the
Committee
Home
on
Office and
Mentally
DHSS.
London: HMSO. Spduucs, R. (1966) The decision to remand for mental examination. British Journal of Criminology,6,6-26. WIrrrE, R. (1975) Psychiatry new-patient clinic non
attenders. BritishJournal of Psychiatry,127,160-2. WoonsmE, M. (1976) Psychiatric referrals from Edinburgh Courts. British Journal of Criminology, 16,20-37.
Paul Bowden, M.Phil.,M.R.C.P.,M.R.C.Psych., Consultant Forensic Psychiatrist, South West Thames Regional Health Authority;
Hon. Senior Lecturer in Psychiafty, St George's Hospital, SWJ7
(Received 28 November 1977; revised 31 March 1978)
A psychiatric clinic in a probation office. P Bowden BJP 1978, 133:448-451. Access the most recent version at DOI: 10.1192/bjp.133.5.448
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/133/5/448#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;133/5/448 http://bjp.rcpsych.org/ on October 3, 2016 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
