FUSIFORM Open door dilemma
How are hospitals supposed to cater for patients who are a security risk and still pursue a progressive, 'open door' policy with the majority of their patients? Dr. Norman Imlah, medical director of All Saints Hospital, Birmingham, puts the case for closed special units. advances in the treatment and
management of the
mentally ill in Britain have brought problems the legislators, but none more pressing than policy of sending offenders from the courts to mental hospitals under Sections 60 and 65 of
for the the the
Mental Health Act. This Act, generally conceded to be enlightened, contains an archaic anomaly; that hospitals pursuing open-door policies, developing various kinds of therapeutic communities and embarking upon community mental health programmes, at the same time are expected to contain patients who, for security reasons, require restricted supervision more akin to prison than a hospital. This anomaly has produced a dilemma for most hospitals?whether to provide the type of restrictions that the court expects for the cases they send, to the detriment of the therapeutic atmosphere of
the hospital,
or to pursue a totally progressive and risk the harm that may result from insufficient security precautions. Most hospitals try to achieve an unhappy and unsatisfactory compromise between the two extremes. Unhappy, because staff today do not think
policy
they
can
promote good, therapeutic relationships
in an atmosphere of restraint for some and nonrestraint for others, particularly so when the existence of restraint is viewed by both staff and patients as a punishing sanction. Nurses do not regard the function of warder as compatible with their role as nurses. Unsatisfactory, because the system does not work. Security in the old mental institution was preserved by a system of discipline that drilled the nurse /attendant into the efficiency of a prison warder. Nurse training is no longer intended to equip the nurse to be a warder and any attempt to do so would be rightfully resisted. The result is that the form of security which exists is an inefficient one, far short of the requirements needed to provide adequate detention of many 36
Section 60 and 65 patients. Even the retention of the locked ward, still favoured by some hospitals, is more of a 'token security' the main consequence of which is to increase the motivation of the patient to escape and is more indicative of the prevailing attitude to patients in the hospital than it is of the degree of security. It provides only a small obstacle to the determined absconder. Patients sent to mental hospitals by the courts under Sections 60 and 65 tend to come into three categories. First, the schizophrenics whose offences, for the most part, are minor. They are charged with vagrancy, petty larceny, or (more rarely) unprovoked assaults and sexual deviancy. The majority do not constitute a serious risk to society but are more of a public nuisance. Their anti-social behaviour does not necessarily arise out of the fact that they have schizophrenia, as schizophrenics on the whole are no less law-abiding than non-schizophrenics, but there is a tendency to regard their unlawful behaviour as a consequence of the illness. The anti-social schizophrenic who breaks the law tends to be a determined absconder from hospital and this is the big problem in their management. This type of patient does not stay long enough for adequate treatment and, even when they can be contained long enough for adequate treatment, the improvement in their mental illness is not necessarily accompanied by a decline in their tendency to break the law. The second category of patients are the sexual deviants, often sent to hospital following very serious offences, including rape. The problem here is not so much the tendency to escape but more the inadequacy of treatment and certainly the inability to produce any marked change on a shortterm basis. The sexual deviant may spend some time in hospital without any alteration in his deviant tendency and at the same time have ample opportunity to leave hospital on impulse, repeat
the
offence, and return to hospital, sometimes withbeing realised that they have been absent for
out it
while. The third group represents the greatest individual problem and the strongest resistance to admission. These are the varying types of psychopathic personalities who go to make up about ten per cent of all cases dealt with under Sections 60 and 65. It is a widely held opinion that these cases are seriously disruptive and unlikely to derive any benefit from treatment in a mental hospital. Therefore they tend to be merely detained and released as soon as the provisions of the Section will allow. To counteract this tendency courts are inclined to put them on Section 65 rather than Section 60, as this places a restriction on their discharge. This restriction does not solve the problem of their frequent escapes from hospital, as they combine the facility to abscond with the frequent committal of an offence, sometimes a very serious offence. Most mental hospitals in Britain have no more than ten or twelve cases in these categories at any one time. Some, depending on location or the special interests of the doctors, may have more than others. All hospitals are expected to make special provision for these cases, but few, if any, are designed or have facilities to physically separate these cases from the rest of the patient population of the hospital. Many have not the staff to provide the supervision that such patients require, except by a disproportionate withdrawal of staff from the needs of the remaining 99% of patients. Nevertheless, a high staff allocation is the only way to minimise the risks that exist at present. Apart from the danger that some innocent citizen may be the victim of an assault under this inadequate system of care, every time such an incident does occur it increases the difficulties of convincing the community that the overwhelming majority of patients leaving a mental hospital can be accepted by the community with complete safety. If we have the right to expect that the community should be tolerant and considerate to the mentally handicapped in their midst, the community also has the right to expect that they will be adequately protected from the small number a
6The real need is for closed units, each with 50-100 places, where the patients can be under the care of the regional forensic
psychiatrist9
of
patients who are potentially dangerous. Not least there is the personal plight of these patients. Under Sections 60 and 65 come cases representative of some of the most difficult and intractable problems in psychiatry. Locking them up in the least accessible chronic wards of the hospital does nothing to improve their condition, nor does it do anything to improve our understanding of them. So far, despite many protestations by psychiatric doctors and nurses, there is little evidence of concern among the legislators and administrators who must act to alter the situation. One Member of Parliament, Mrs. Jill Knight, is concerned and has raised the matter in the House of Commons in a Private Members Bill. One must hope that others follow her enlightened example. The biggest obstacle to rectifying this situation is money and nobody knows better than people in the mental health services that money is a very scarce commodity. An additional special hospital has been suggested but, though this may be desirable to ease the existing pressure in Broadmoor, it is not the best solution for the cases which fall somewhere between the special hospital and the ordinary mental hospital. The real need is for a number of closed special units, each with 50?100 places, situated near the main regional centres, where the patients can be under the care of the regional forensic psychiatrist. Recently a number of joint Home Office/ Regional Hospital Board appointments for consultants in forensic psychiatry have been set up. These appointments should now be linked with the provision of special forensic psychiatric units. These cannot be created by taking over part of some of the existing mental hospitals and converting them to this use because it would merely accentuate for a few hospitals the problem that currently concerns them all but, apart from this, the hospitals as they exist are not suitable for such a makeshift solution. The requirement is for purpose-built units which will offer maximum security outside, but which will allow inside freedom to develop to the full a special kind of therapeutic community.
be geographically and adminiswith existing hospitals to allow services and facilities and to provide an avenue for the progression back into the community of those patients who are sufficiently improved to take this step with safety. In this way the patients themselves would get a better deal therapeutically, the community outside the hospital would feel more comfortable, and the mental hospitals would be free to pursue progressive policies, free from the shadows of the last vestiges of custodial care. Such units
can
tratively linked some sharing of
How are hospitals supposed to cater for patients who are a security risk and still pursue a progressive, 'open door' policy with the majority of their patients? Dr. Norman Imlah, medical director of All Saints Hospital, Birmingham, puts the case for closed special units. advances in the treatment and
management of the
mentally ill in Britain have brought problems the legislators, but none more pressing than policy of sending offenders from the courts to mental hospitals under Sections 60 and 65 of
for the the the
Mental Health Act. This Act, generally conceded to be enlightened, contains an archaic anomaly; that hospitals pursuing open-door policies, developing various kinds of therapeutic communities and embarking upon community mental health programmes, at the same time are expected to contain patients who, for security reasons, require restricted supervision more akin to prison than a hospital. This anomaly has produced a dilemma for most hospitals?whether to provide the type of restrictions that the court expects for the cases they send, to the detriment of the therapeutic atmosphere of
the hospital,
or to pursue a totally progressive and risk the harm that may result from insufficient security precautions. Most hospitals try to achieve an unhappy and unsatisfactory compromise between the two extremes. Unhappy, because staff today do not think
policy
they
can
promote good, therapeutic relationships
in an atmosphere of restraint for some and nonrestraint for others, particularly so when the existence of restraint is viewed by both staff and patients as a punishing sanction. Nurses do not regard the function of warder as compatible with their role as nurses. Unsatisfactory, because the system does not work. Security in the old mental institution was preserved by a system of discipline that drilled the nurse /attendant into the efficiency of a prison warder. Nurse training is no longer intended to equip the nurse to be a warder and any attempt to do so would be rightfully resisted. The result is that the form of security which exists is an inefficient one, far short of the requirements needed to provide adequate detention of many 36
Section 60 and 65 patients. Even the retention of the locked ward, still favoured by some hospitals, is more of a 'token security' the main consequence of which is to increase the motivation of the patient to escape and is more indicative of the prevailing attitude to patients in the hospital than it is of the degree of security. It provides only a small obstacle to the determined absconder. Patients sent to mental hospitals by the courts under Sections 60 and 65 tend to come into three categories. First, the schizophrenics whose offences, for the most part, are minor. They are charged with vagrancy, petty larceny, or (more rarely) unprovoked assaults and sexual deviancy. The majority do not constitute a serious risk to society but are more of a public nuisance. Their anti-social behaviour does not necessarily arise out of the fact that they have schizophrenia, as schizophrenics on the whole are no less law-abiding than non-schizophrenics, but there is a tendency to regard their unlawful behaviour as a consequence of the illness. The anti-social schizophrenic who breaks the law tends to be a determined absconder from hospital and this is the big problem in their management. This type of patient does not stay long enough for adequate treatment and, even when they can be contained long enough for adequate treatment, the improvement in their mental illness is not necessarily accompanied by a decline in their tendency to break the law. The second category of patients are the sexual deviants, often sent to hospital following very serious offences, including rape. The problem here is not so much the tendency to escape but more the inadequacy of treatment and certainly the inability to produce any marked change on a shortterm basis. The sexual deviant may spend some time in hospital without any alteration in his deviant tendency and at the same time have ample opportunity to leave hospital on impulse, repeat
the
offence, and return to hospital, sometimes withbeing realised that they have been absent for
out it
while. The third group represents the greatest individual problem and the strongest resistance to admission. These are the varying types of psychopathic personalities who go to make up about ten per cent of all cases dealt with under Sections 60 and 65. It is a widely held opinion that these cases are seriously disruptive and unlikely to derive any benefit from treatment in a mental hospital. Therefore they tend to be merely detained and released as soon as the provisions of the Section will allow. To counteract this tendency courts are inclined to put them on Section 65 rather than Section 60, as this places a restriction on their discharge. This restriction does not solve the problem of their frequent escapes from hospital, as they combine the facility to abscond with the frequent committal of an offence, sometimes a very serious offence. Most mental hospitals in Britain have no more than ten or twelve cases in these categories at any one time. Some, depending on location or the special interests of the doctors, may have more than others. All hospitals are expected to make special provision for these cases, but few, if any, are designed or have facilities to physically separate these cases from the rest of the patient population of the hospital. Many have not the staff to provide the supervision that such patients require, except by a disproportionate withdrawal of staff from the needs of the remaining 99% of patients. Nevertheless, a high staff allocation is the only way to minimise the risks that exist at present. Apart from the danger that some innocent citizen may be the victim of an assault under this inadequate system of care, every time such an incident does occur it increases the difficulties of convincing the community that the overwhelming majority of patients leaving a mental hospital can be accepted by the community with complete safety. If we have the right to expect that the community should be tolerant and considerate to the mentally handicapped in their midst, the community also has the right to expect that they will be adequately protected from the small number a
6The real need is for closed units, each with 50-100 places, where the patients can be under the care of the regional forensic
psychiatrist9
of
patients who are potentially dangerous. Not least there is the personal plight of these patients. Under Sections 60 and 65 come cases representative of some of the most difficult and intractable problems in psychiatry. Locking them up in the least accessible chronic wards of the hospital does nothing to improve their condition, nor does it do anything to improve our understanding of them. So far, despite many protestations by psychiatric doctors and nurses, there is little evidence of concern among the legislators and administrators who must act to alter the situation. One Member of Parliament, Mrs. Jill Knight, is concerned and has raised the matter in the House of Commons in a Private Members Bill. One must hope that others follow her enlightened example. The biggest obstacle to rectifying this situation is money and nobody knows better than people in the mental health services that money is a very scarce commodity. An additional special hospital has been suggested but, though this may be desirable to ease the existing pressure in Broadmoor, it is not the best solution for the cases which fall somewhere between the special hospital and the ordinary mental hospital. The real need is for a number of closed special units, each with 50?100 places, situated near the main regional centres, where the patients can be under the care of the regional forensic psychiatrist. Recently a number of joint Home Office/ Regional Hospital Board appointments for consultants in forensic psychiatry have been set up. These appointments should now be linked with the provision of special forensic psychiatric units. These cannot be created by taking over part of some of the existing mental hospitals and converting them to this use because it would merely accentuate for a few hospitals the problem that currently concerns them all but, apart from this, the hospitals as they exist are not suitable for such a makeshift solution. The requirement is for purpose-built units which will offer maximum security outside, but which will allow inside freedom to develop to the full a special kind of therapeutic community.
be geographically and adminiswith existing hospitals to allow services and facilities and to provide an avenue for the progression back into the community of those patients who are sufficiently improved to take this step with safety. In this way the patients themselves would get a better deal therapeutically, the community outside the hospital would feel more comfortable, and the mental hospitals would be free to pursue progressive policies, free from the shadows of the last vestiges of custodial care. Such units
can
tratively linked some sharing of
