Challenging Risk: A Critique of Defensive Practice
Perhaps one of the most obvious manifestations of liberatory psychiatry was the Congress on the Dialectics of Liberation held in London at the Roundhouse in Chalk Farm in July 1967. David Cooper (1968) designated the four organisers of the Congress as anti-psychiatrists. Besides himself, these were R.D. Laing, Joseph Berke and Leon Redler. Both Laing and Cooper gave papers at the conference, as did celebrated social theorists such as Herbert Marcuse and political activists such as Stokely Carmichael.
To free a generation was the alternative title of the book of the conference The dialectics of liberation (Cooper, 1968). This description makes clear that the book was concerned with how liberation may be achieved. The strands of anti-psychiatry were interwoven with the 1960’s counterculture whose aim was to free the spirit of the age from the nightmare of the world (Nuttall, 1970). The writings of R.D. Laing, perhaps especially The politics of experience and The bird of paradise, helped to articulate this perspective. Laing (1967) was explicit that civilisation represses transcendence and so-called ‘normality’ too often abdicates our true potentialities.
Psychedelic drugs seemed to expand the limits of immanent experience (Wolfe, 1989). One of the originators of hippie culture, Ken Kesey who, with his Merry Pranksters drove across America in a brightly painted bus, wrote One flew over the cuckoo’s nest (Kesey, 1963). This successful novel depicts Randle McMurphy’s attempt, possibly on behalf of the counterculture, to overthrow the bureaucratic control of Nurse Ratched in the psychiatric institution.
David Cooper was the most radical of the anti-psychiatrists in his quest for freedom. He wanted liberation from the family, which he saw as an ideological conditioning device that reinforces the power of the ruling class in an exploitative society (Cooper, 1971). Besides being Marxist in his political refusal to submit to bourgeois society, he thought that spontaneous self-assertion of full personal autonomy should be a decisive act of counter-violence against the system. He argued for sexual liberation of an orgasmic ecstasy (Cooper, 1974). He even believed that initiation of young children into orgasmic experiences should become part of a full education
What is not always clear is that R.D. Laing distanced himself from Cooper’s excesses. Where they were agreed was that the social practice of psychiatry needed to change. They both wanted to give people freedom from the social control of psychiatry. I want to explore further what this means in this chapter, and relate it to the current psychiatric scene. I describe the therapeutic alternatives of anti-psychiatry and in particular note the motivation for reform because of the institutional effects of the asylum. Psychiatry does have a social role and this cannot be avoided, however much the anti-psychiatrists may have wished they could. Mental health services manage the risk of mental illness on behalf of society and how they do this determines how liberated people will be. We have moved on from the time of anti-psychiatry as the traditional psychiatric hospital has continued to be rundown. Where anti-psychiatry railed against the excesses of the institution, the development of community care has created a different environment. I discuss the effect of inquiries in the UK: first of all, in relation to mistreatment in hospital; and then in criticisms of community care because of homicides by psychiatric patients. I conclude that the over-bureaucratic way in which modern psychiatric services tend to respond to the management of risk in the community has many of the features of the worst excesses of the asylums.
Anti-psychiatry and liberation
David Cooper (1967) set up Villa 21 in Shenley Hospital between 1962 and 1966. He tried to create a community in which patients would have the chance to discover and explore an authentic relatedness to each other. To do this required "an effort to cease interference, to ‘lay off’ other people and give them and oneself a chance " (Cooper, 1967: p89). Being allowed to ‘go to pieces’ was necessary before one could be helped to come back together again. When staff controls had to be re-introduced to gain some semblance of order on the ward, Cooper concluded that a successful unit could only be developed in the community rather than in hospital.
Both Laing and Cooper were part of the Philadelphia Association that established Kingsley Hall in 1965, although Cooper had nothing more to do with this project after it started (Mullan, 1995). Laing lived at Kingsley Hall for 18 months in 1965/6. Kingsley Hall was an experiment in unstructured living. It sought to allow psychotic people the space to explore their madness and internal chaos. It did not attempt to ‘cure’ but provided a place where "some may encounter selves long forgotten or distorted" (Schatzman, 1972). The local community was mostly hostile to the project. After five years Kingsley Hall was largely trashed and uninhabitable. Laing’s dream of a place "without those features of psychiatric practice that seemed to belong to the sphere of social power and structure rather than to medical therapeutics" was only partially successful, even from his own perspective (Laing, 1985).
The association of anti-psychiatry with the counterculture of the 1960s and 1970s may have helped to propel anti-psychiatry into the limelight. It may also have contributed to its demise. Without this cultural support, anti-psychiatry seemed to lose its popular appeal. Also, some of its major proponents, such as Laing, were more obviously interested in personal authenticity than changing psychiatry practically. After Kingsley Hall, Laing went on retreat to Ceylon and India to pursue his interests in meditation, Buddhism and Hinduism. Later in life, Laing (1987) regarded his main achievement as being in the area of social phenomenology in philosophy, not psychiatry. Generally, anti-psychiatry is seen as having had no lasting influence on psychiatry and its practice (Tantam, 1991). For all its calls for liberation, these aspirations were largely sidelined into promoting personal and spiritual freedom with little interest in redeeming psychiatry itself. This diversion helped to allow mainstream psychiatry to marginalise anti-psychiatry’s influence.
One exception to this evaluation of the significance of anti-psychiatry would be the achievement of Franco Basaglia in changing mental health law in Italy. Basaglia’s awareness of the effects of institutionalisation led to his struggle to abolish the asylum. He recognised the necessary political, class-related character of this fight. From his point of view, the asylum contained poverty and misery not madness. As expressed by his wife, with whom he worked closely, the asylum was "a dumping ground for the under-privileged, a place of segregation and destruction where the real nature of social problems was concealed behind the alibi of psychiatric treatment and custody" (Basaglia, 1989). Politically Basaglia was influenced by the writings of Antonio Gramsci, a co-founder of the Italian communist party (Mollica, 1985). Health care workers, such as doctors, nurses and students, regarded as ‘technicians of practical knowledge’, were encouraged to contest their roles and recognise the social and political context of psychiatric problems. This attitude led to the mass resignation of the doctors at Gorizia in protest at the failure to invest in community services. In terms of liberatory psychiatry, this could be seen as a pre-eminent refusal to be accomplices of the system.
Psichiatria Democratica was founded in 1973 and acted as a pressure group leading to the passing of Law 180 by the Italian parliament in May 1978. The new law prevented new admissions to existing mental hospitals and decreed a shift of perspective from segregation and control in the asylum to treatment and rehabilitation in society. The mental health services in Trieste, where Basaglia worked, became seen as the most important representation of the success of democratic psychiatry.
The negative effects of institutionalisation
The example of Basaglia confirms that liberatory psychiatry is closely entwined with the social aspects of psychiatric practice. Initially Basaglia was struck by the effects of institutionalisation, which Russell Barton (1959) called a disease, for which he coined the term ‘institutional neurosis’. This syndrome was characterised by symptoms such as apathy, lack of initiative, loss of interest and submissiveness. The cause was said to be factors such as loss of contact with the outside world, enforced idleness, brutality and bossiness of staff, loss of friends and personal possessions, poor ward atmosphere and loss of prospects outside the institution.
The negative effects of the process of institutionalisation were Basaglia’s motivation for change. This notion fits with the interests of the anti-psychiatrists in general in the negative effects of institutionalisation in the asylums (Goffman, 1961). For example, both Joseph Berke and Leon Redler came from the USA to work with Maxwell Jones at Dingleton before moving to collaborate with Laing. The therapeutic community movement, based on ideas of equality, informality and frank and open discussion, was pioneered in psychiatry by Jones (1952). It challenged traditional asylum assumptions. One of the constructive and lasting outcomes of anti-psychiatry could be seen as the therapeutic communities established by the Philadelphia Association, founded by Laing and others, and the Arbours Association, set up by Berke and Morton Schatzmann.
Although debates about community care are no longer as polarised as they were in the past, many psychiatrists felt threatened by their perceived loss of power due to the rundown of the traditional psychiatric hospital. Anti-psychiatry reinforced this challenge to psychiatric power and became identified with the closure of the traditional asylum, even though there is not necessarily a logical link. For example, in a brief appendix to the third edition of Being mentally ill, Thomas Scheff (1999) notes that the first edition of his book was regarded as the "Bible" of the group that wrote a bill that became the new mental health law for California, and later for the rest of the United States. The new law made it more difficult for people to be kept in hospital indefinitely, which in the long run could be said to have contributed to the subsequent closure of mental hospitals.
The motivation to create a therapeutic milieu from the traditional psychiatric hospital has a long history and is much wider than anti-psychiatry. For example, Harry Stack Sullivan established a small ward for schizophrenic men that was staffed with hand-picked attendants, set apart from the rest of the Sheppard Pratt Hospital in the 1920s (Barton Evans III, 1996). He gave his staff autonomy to operate on their own with patients. He found unexpected genuine relationships flourished between patients and staff leading to an improvement in institutional recovery (Sullivan, 1962). Another example is from Laing again, before Kingsley Hall, when he was involved in an experimental therapeutic venture within the health service as a psychiatric trainee at Gartnavel hospital in Scotland (Andrews, 1998). The nurses called the project the ‘Rumpus Room’. It recognised the role that the hospital environment had in ‘enforced inactivity’ of patients, and encouraged patients and nurses to develop personal relationships of a reasonably enduring nature.
Although anti-psychiatry was explicit in its wish to overthrow psychiatric control, there were more general moves to open up psychiatric practice through recognition of human relations and group dynamics. For example, the World Health Organisation (1953) promoted the creation of an atmosphere of a therapeutic community as an important element in treatment, heralding the opening of the locked doors in mental hospitals and the rundown of the traditional asylum. Elements of this therapeutic atmosphere included encouraging patients’ self-respect and sense of identity; and the general assumption that patients are trustworthy and retain capacity for a considerable degree of responsibility and initiative. Purposeful, planned activity was promoted in a patient’s day.
I want to explore further the social nature of psychiatry by studying its political context over recent years in the development of community care. Questions about how to care for the mentally ill and whether this should take place in hospital or in the community make apparent the propensity for abuse and neglect of these people. Evident failures in care highlight the tension between controlling patients on behalf of society and helping them to find individual and personal fulfilment and liberation.
The development of community care and the role of inquiries
Psychiatry’s social role is reinforced through mental health legislation. Using the UK as an example, the Lunatic Asylums Act 1845 made it mandatory for each borough and county to provide adequate asylum accommodation at public expense for its pauper lunatic population. This led to an asylum building programme, but the asylums quickly became overcrowded institutions.
In the 1950s, the locked doors of the psychiatric hospitals started to be opened. The peak of the mental health population in the UK and USA was the mid-1950s and later in other Western countries (Goodwin, 1997). The traditional asylums became increasingly irrelevant to the bulk of mental health problems and began their decline as alternative services were developed, including psychiatric units in general hospitals, residential homes and day centres. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them has been much less. Despite the massive reduction in bed space and the closure of most of the traditional asylums, there has in fact been an increase in the admission rates to psychiatric hospital. What has happened is that the average length of stay has been considerably reduced, although a small minority of people still experience protracted hospital admissions (Goodwin, 1993).
Abuses and over-restrictive practices within institutions
One of the features that encouraged the rundown of the psychiatric hospital was the recognition of the potential harm caused by psychiatric hospitalisation. Again using the UK as an example, there were a number of scandals that uncovered mistreatment of patients in hospital (Martin, 1984). Detaining the mentally ill under the Mental Health Act may exacerbate the potential for abuse.
A phase of public concern and debate was launched by the Ely Hospital inquiry (see Martin, 1984, for further details). In 1967 a nursing assistant at Ely Hospital in Cardiff made a series of allegations about the treatment of patients and the pilfering of property by staff. These allegations were published in the Sunday newspaper News of the World. The inquiry found examples of callous, ‘old fashioned and unsophisticated’ techniques of nursing control. Although in most instances this practice was not ‘wilful or malicious’, nursing standards were low, supervision weak, reporting of incidents inadequate, and training of nursing assistants virtually non-existent. Staff were found to have pilfered supplies of food. There were determined and vindictive attempts to silence complainants. It also transpired that members of the Nursing Division of the Ministry had visited Ely some years before and had reported ‘scandalous conditions, bad nursing’, and yet nothing had been done about it. In essence the inquiry report confirmed the basis of all the News of the World revelations.
Another example of an influential inquiry was the Whittingham Hospital inquiry (again, see Martin, 1984, for further details). In 1969 two senior members of the staff at Whittingham Hospital near Preston, Lancashire, made allegations of ill-treatment of patients, fraud and maladministration, including suppression of complaints from student nurses. Two male nurses were convicted of theft. Shortly after the police investigation a male nurse assaulted two male patients, one of whom died. The nurse was convicted of manslaughter and imprisoned. An inquiry was set up after the trial was over. What was significant about the report was that it placed the responsibility on the management for the institutional conditions that led to callous and incompetent nursing and some deliberate cruelty. The inquiry also uncovered suppression and denial of student nurses’ complaints about ill-treatment.
The political response in the UK to this series of inquiries was to set up the Hospital Advisory Service, which, independent of the normal departmental machinery, provided visiting teams for inspecting hospitals. The other main consequence was the government’s renewal of its promotion of the policy of community care. The view was strengthened that society should not reject its mentally ill and handicapped people. No longer was it appropriate to consign these people to distant institutions where they lived their lives out of sight and mind of the rest of society, with the potential for them being abused (Martin. 1984). The white papers Better services for the mentally handicapped (Department of Health and Social Security & Welsh Office, 1971) and Better services for the mentally ill (Department of Health and Social Security, 1975) were published. Mental illness hospitals were to be replaced by a local and better range of facilities. On the other hand, the government also wanted to correct the misapprehension that it was actively encouraging a precipitate rundown of psychiatric hospitals.
These inquiries generally had a positive effect and aimed to encourage ethically acceptable professional behaviour in the institution. However, inquiries may not always be as perspicacious as they seem (Walshe & Higgins, 2002). They can have a serious effect on staff morale if they reach incorrect conclusions because of, for example, poor methodology or their inquisitorial nature. Although we live in a ‘risk society’ (Beck, 1972), there is a responsibility to avoid 'scapegoating' and a culture of blame. The accountability of clinical governance should be sound, open and fair, but in practice this is not always the case. This arises from the notion that errors, particularly those that have bad outcomes, are manifestations of incompetence, carelessness or recklessness. However, fallibility is the norm, and not necessarily a moral issue.
Flaws with inquiries have perhaps become particularly manifest with inquiries into failure of community care over recent years. Again in the UK, since 1994 health authorities have been obliged to hold an independent inquiry in cases of homicide committed by those who have been in contact with the psychiatric services (Buchanan, 1999). These inquiries reflect a shift from focusing on abuses and over-restrictive practices within institutions towards anxiety about the lack of control in the community (Crichton & Sheppard, 1996). The presence of asylums may have sustained a belief that it is part of the role of psychiatric services to shield society from its madness (Salter, 2003). Without these structures for confinement, society may feel more at risk.
The problem is that too often these inquiries have been destructive and reform of the current system of such investigations has been proposed (King et al, 2006). I want to look at the context in which these inquiries developed.
Anxiety about lack of control in the community
Community care has been a controversial policy. Campaigners against the rundown of the traditional psychiatric hospitals opposed the policy in various ways. Initially they focused on the apparent risk of homelessness after discharge from hospital (Weller, 1989). Because of the evident relatively high level of mental illness amongst the homeless population, it was concluded that patients were being discharged irresponsibly from the traditional asylums ‘onto the street’. However, follow-up studies of discharged patients showed that the rundown of the psychiatric hospital, at least in the UK, was not the main factor contributing to the increase in the numbers of homeless mentally ill (Leff, 1993). The number of homeless people seems to have been affected more by housing policy than by psychiatric deinstitutionalisation. The reason in particular may have been the reduction in direct access hostels, which since the mid-1950s seemed to serve as unacknowledged refuges for some mentally ill people (Craig & Timms, 1992).
When evidence accumulated against the view that psychiatric dehospitalisation was increasing homelessness and criminal imprisonment, the tack of campaigning organisations such as SANE (http://www.sane.org.uk/) changed to concern about public safety due to homicides by psychiatric patients. The tragic killing of Jonathan Zito on the London Underground led to the formation of the Zito Trust. The victim’s widow, Jayne Zito, was understandably motivated to improve mental health services. She was prevented from pursuing a negligence claim in relation to her husband’s death, because UK courts are loath to rule that public bodies, such as mental health services, owe a duty of care to third parties.
Campaigners such as these led the newly elected Labour government to conclude that community care had failed (Department of Health, 1998a). The government strategy document Modernising mental health services (Department of Health, 1998b) stated that the policy of community care had brought many benefits. It also suggested that underfunding, inadequate care and poor management had caused the failures in policy.
The public cannot be totally safeguarded against homicides by mentally ill people. As homicide is rare, attempts to prevent such tragedies risk high false negative prediction. Assuming it were possible to recognise patients at high risk of committing homicide with sufficient sensitivity and specificity, it has been estimated that for every one person detected correctly, 5000 people will be identified as being at high risk of committing homicide but will not do so (Crawford, 2000). Despite the hype in the media, single cases do not necessarily constitute evidence of the failure of the system of community care. UK national homicide figures in fact show a 3% annual decline in the proportion of mentally disordered people contributing to homicide figures (Taylor & Gunn, 1999). Such findings by themselves give no basis to the argument for change in community care policy.
Public outcry about mental health services may have been counterproductive by encouraging defensive rather than therapeutic practice. Over recent years, more people have been locked up in secure beds in the UK as numbers of other adult mental health beds have reduced. Numbers of people detained under the Mental Health Act have increased (Wall et al, 1999).
Moreover, homicide inquiries can have devastating consequences for mental health services (Szmukler, 2000). They are not always based on rational foundations. The stereotype of the ‘dangerous lunatic’ is reinforced and public fears of the mentally ill are fuelled. To quote from Szmukler (2000)
An assumption reigns, among the media and politicians at least, that all such homicides are preventable, despite the fact that every country has, and has always had them. For some reason, ours has become terrorised by them. (p6)
Many reports are long and have been very expensive to complete. For example, there are two volumes of the report of the Luke Warm Luke mental health inquiry (Scotland et al, 1998), which cost £750,000. Luke Warm Luke (formerly Michael Folkes) stabbed to death Susan Milner, aged 33, in 1994. Michael Folkes had changed his name by deed poll to Luke Warm Luke, apparently taking the name from a character in the Porridge series on television. He was convicted of manslaughter and made the subject of a hospital order with restrictions and sent to Broadmoor Hospital, a high-security special hospital. The murder he committed was known in the press as the 'scissors death', as he stabbed his girlfriend to death 70 times with scissors at his London flat.
Luke Warm Luke had been diagnosed as suffering from paranoid schizophrenia and had been in and out of mental health facilities since 1983. He was released by a Mental Health Review Tribunal against Home Office and expert advice on the condition that he continued to take his medication. However, he later refused to take his depot injection and was allowed to take his medication orally. Tests after the attack demonstrated no traces of medication in his body. The day before the attack he had gone to the Maudsley hospital in a distressed state. He was put on an emergency list for a community psychiatric nurse to visit.
The inquiry team criticised the lack of communication in the community care team dealing with the case. The three members of the aftercare team did not meet together in the 25 months leading up to the killing. They also criticised the decision to allow Luke Warm Luke to discontinue his depot medication. The report also said he should have been discharged into a staffed hostel so that he was not forced to look after himself. It said that the killing bore a striking similarity to an attack committed the year before and that both attacks could have been prevented if Luke Warm Luke had been admitted to hospital.
Despite the length of the report, it is unclear why Luke Warm Luke killed Susan Milner. The only explanation offered is that he was schizophrenic. This is regarded as a sufficient and complete explanation. There is no questioning of this connection. The simple, almost naïve view is that schizophrenia is a biological illness that determines how a person behaves, especially if they are violent. Any court exercising its proper role would never let a forensic psychiatrist get away with such an oversimplification. Yet inquiries can produce authoritative reports based on this kind of assumption.
As Szmukler (2000) points out, Luke Warm Luke’s history of serious violence, which antedated the illness, was passed over without comment by the inquiry panel. Furthermore, the focus on mental health services tends to exclude the role of other actors in the drama. For example, Luke Warm Luke’s victim visited the patient at 3 am despite advice from friends not to do so. Earlier that night, he had threatened (with scissors) another young woman he had known. This woman called the police at about 10 pm, but the police did not follow-up on the incident because she did not want to press charges.
Szmukler (2000) goes on to discuss whether it is reasonable to be held responsible for the action of another and suggests it is unprecedented in medicine. It occurs in social work where child protection teams may be held responsible for the behaviour of an abusing parent. However, at least in social work the child protection team can focus on preventing harm to children. The pattern of relationships of a mentally ill person is generally more complex. Moreover, the overall evaluation of child abuse inquiries has been that the preoccupation of many inquiry panels with apportioning blame has limited the lessons that could be learnt (Reder et al, 1993). Understanding complex cases requires an approach that goes beyond blaming.
To reinforce this message, I give another example of a homicide inquiry from my own NHS provider organisation (Norfolk & Waveney Mental Health Partnership NHS Trust, 2005). Richard King was convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004 and made the subject of a hospital order with restrictions. He had been in receipt of adult mental health services since 1989. The panel concluded the homicide occurred because of his mental illness and that although it was not predictable, it was preventable because he should have been detained under the Mental Health Act.
It is clear that the Trust panel was motivated by what it saw as the public expectation that mental health services should exert some influence over the behaviour of individuals in their care. The report was written to maintain this public confidence in mental health services by identifying mistakes and errors of judgement. However, it is not necessarily the role of an inquiry report to meet these stated public expectations. If that were the case it would mean that homicide inquiries were being used to achieve political aims.
The report did not demonstrate that staff acted in bad faith, nor without reasonable care. These are the criteria that should first of all be used to assess their actions rather than mistakes and errors of judgement. No professional system ever works perfectly. There will always be weaknesses. The panel report, like other homicide inquiries, was also written with the benefit of hindsight, which often leads to a biased perspective on clinical judgements that have to be made in the course of everyday clinical work. Nor is it as clear as the panel make out that detention under the Mental Health Act was indicated. Compulsory treatment is only necessary if treatment cannot be provided unless the person is detained. Informal admission without use of the Mental Health Act seems to have been a viable alternative to detention in this case.
My comments on the panel’s report should not be seen as encouraging complacency. They are intended to improve the quality of care for patients. The problem of the report is that it is likely to encourage defensive practice and lead to a worsening of care. After all, inquiries are as likely to make as many mistakes as the services they criticise, particularly if undertaken by the organisation itself. It is extremely unfortunate that homicides by psychiatric patients are used to attack mental health services.
Risk and mental health
I want to move on to discuss the role of ‘risk’ more generally. The notion of risk is related to liberation in the sense that freedom may be achieved by taking risks. Over-defensiveness because of ‘risk’ can be alienating, unsound and counterproductive. For example, one of the common outcomes of homicide inquires has been to encourage an ever more rigid and bureaucratic interpretation of the Care Programme Approach, the attempt within the UK to systematise the approach to care. This is despite the difficulties of showing that deficiencies in this regard are in fact related to outcome (Szmukler, 2000).
Anthony Giddens (1991) sees Britain as living in a post-traditional society in which the ‘Risk Society’ is the context of politics. Over recent years, risk has become an academic growth area. Some of the stimulus for this increase has been the work of Mary Douglas (1992), in particular her book Risk and blame. The subtitle of her book, ‘Essays in cultural theory’, indicates that her work is at least partly about method. What I want to look at, like Mary Douglas, is how we view risk, in particular in relation to mental health.
People have certain ways of living in relation to institutions. There is always a political question about what is acceptable risk. In particular, there is a debate about the balance between risk taking and risk avoidance. If anything, what the ‘Risk Society’ means is a shift towards the risk aversive end of this relationship. The word ‘risk’ has been pre-empted to mean bad risks. The promise of a good political outcome is couched in other terms. Yet any society which did not take risks would not be making the most of its opportunities for growth. Over-cautious behaviour can be counterproductive and crippling. The debate also relates to authority, and oscillates between the pressures to move on from the old institutional constraints and the pressures to sustain the institutions in which authority and solidarity are seen to reside.
The important point is that we need to be aware that debates about ‘risk’ in mental health are political debates. As mentioned above, when New Labour came to power there was an increased emphasis on public safety in mental health in the context of suggesting that community care had failed. Even though this rhetoric may be less commonly used now by a more experienced administration, we need to see government concern for public safety for what it is. Any history of the opening of the traditional asylum doors, such as that by David Clark (1996) of Fulbourn Hospital, highlights the risks that were taken at the time, and the emotional turmoil that ensued from taking such decisions. Nonetheless, overall the changes were therapeutic for patients and perhaps could be seen as the most progressive advance in psychiatric treatment over recent years. What was needed was to move on from the state of affairs which involved
issuing memoranda, forbidding activities, putting up warning notices, setting up disciplinary enquiries and penalising staff who take risks or show initiative. Staff have learned to be cautious, to get everything in writing, to avoid initiative (Clark, 1996).
We seem to have gone full circle and at times our systems in community care are as bureaucratic as those in the traditional asylums. We need to be bold enough to point out that regarding risk assessment in mental health as a purely clinical activity is not sensible. It has become very common following inquiries into homicides by psychiatric patients to hear the recommendation that risk assessment needs to be improved and that staff should receive further training in risk assessment. But will this really lead to any improvement? Does merely knowing about risks improve practice? Is risk assessment really such a separate part of the overall evaluation of a patient? We actually have very little reliable knowledge about the accurate clinical quantification of risk (Geddes, 1999).
A guiding influence in UK government mental health policy over recent years has been the National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness. The NCI collects data on deaths by suicide and homicide by psychiatric patients. It makes recommendations on clinical practice with the aim of reducing the risk of suicide and homicide. Its Director, Professor Louis Appleby, is also the National Director of Mental Health, commonly known as the mental health ''tsar", and an important advisor to government. The work of the NCI has been said to provide evidence that amending the Mental Health Act to extend powers for compulsory treatment in the community will help save lives.
The simplistic argument is made that treated, even forcibly treated, mentally ill people are less likely to commit suicide and murder than mentally ill people who are untreated. However, services can make improvements in mental health, but they can also make matters worse. This follows inevitably from the power of psychiatry to do ‘good’. Having control and influence implies that there is also the potential for doing harm. Psychiatric interventions aim to be effective, but a good outcome does not necessarily follow logically or in practice. Inappropriate psychiatric treatment could potentially increase the risk of deaths by suicide or homicide. However inconceivable this may be for politicians and mental health services, it does need to be considered. As it is so difficult to think about it, only the advantages of the introduction of enforced community treatment are proclaimed officially, rarely the disadvantages. But overactive intervention may be counterproductive. Inappropriate imposition of compulsory community treatment may precipitate the acting out of more risky behaviour, rather than contain the risk.
The UK has been slower than some other countries in introducing enforced community treatment. Outpatient commitment is permitted in virtually all US states, eg. New York's "Kendra's Law". The operation and use of outpatient commitment varies dramatically between states. Undesirable effects are acknowledged, particularly the creation of barriers to care. For example, treatment adherence and therapeutic alliance can be adversely affected (van Dorn et al, 2006). The evidence for effectiveness in, for example, reducing either admissions or bed-days is very limited and other effects are uncertain (Kisely et al, 2006).
The debate in the UK about amending the Mental Health Act is still ongoing, driven by the notion that deaths by homicide and suicide are avoidable by increased coercion. The NCI even went as far in one of it reports, Safer Services, to estimate the potential number of deaths that would be prevented by the introduction of community treatment orders (Appleby et al, 1999). This relied on making various assumptions. It could have produced a higher or lower figure dependent on different assumptions. The fact is that whatever figure was produced is not evidence of the value of compulsory community treatment, as it is only an estimate calculated if this intervention is effective. Unthinking implementation of enforced community treatment risks undermining patients’ rights. This momentum could be seen as reflecting a lack of tolerance for mental illness in society. Unrealistic efforts to control risk may inappropriately restrict freedom of thought and action. A government which promulgates the aim of social inclusion will be judged by its policies towards the mentally ill.
Defensive practice and critical psychiatry
I have discussed the recent history of psychiatry in the context of the development of community care. Psychiatry does have a social role. It is the sign of a humane society that it has high quality mental health services. When disturbed, mentally ill people may need to be protected from the harm they may cause to themselves and others. Assessment of risk needs to be realistic and not exaggerated for fear of exacerbating stigma. Prediction of future behaviour is very difficult and society will never prevent all tragedies such as suicide and homicide. How society reacts to irrationality, disturbance and madness does matter.
As well as this social aspect, individuals seek personal fulfilment and liberation. The danger is that the fear that things may go wrong in mental health services is distracting us from the task of how to make things better for people (Cooper, 2001). We may follow procedures that are more for the purpose of protecting staff than helping patients. Examples of such defensive practice in psychiatry would be admitting patients overcautiously and placing patients on higher levels of observation than necessary (Passmore & Leung, 2002). ‘Specialing’ of patients on acute psychiatric wards highlights the impersonal nature of such bureaucratic practice (Buchanan-Barker & Barker, 2005). As we have seen from the discussion of inquiries into psychiatric hospitals, the extreme end of this trend is that patients are abused and neglected.
I want to look in a little more detail at the nature of defensive practice. This hinges on the role of professional knowledge and clinical judgement. Health managers can influence direct clinical care through imposing regulations. Over recent years attempts have been made to make professionals more accountable and this has led to a crisis of trust (O’Neill, 2002). Such ‘proceduralism’ emphasises external criteria for assessing and evaluating our work, rather than internal factors (Cooper, 2001). The danger is that concern for improvement is not authentic and merely a facade to placate society's fears. Managerial guidelines can never be a complete substitute for clinical judgement.
I am not saying there are no potential advantages of an audit culture. Increasing understanding, learning from practice and a desire to improve performance should be encouraged. However, fear of being criticised and unfairly judged does not lead to creative thinking about the quality of services. What is needed is a learning culture with excellent leadership that provides an ethos where staff are valued and supported as they form partnerships with patients (Halligan & Donaldson, 2001). Few mental health services have the courage to provide such an environment when they are overly concerned to protect themselves against criticism.
Healthcare systems are complex which means there is much uncertainty in clinical practice. Gaps in care, such as losses of information or interruptions of delivery of care, are commonplace (Cook et al, 2000). Fortunately these gaps rarely produce too many difficulties. Usually they are anticipated, detected or bridged in some way. What may lead to adverse clinical incidents are gaps which practitioners are unsuccessful in bridging. Conditions to improve patient safety are, therefore, those that facilitate practitioners in bridging gaps, not the reverse. Focusing too much on failures to adhere to narrow procedural guidelines misses the point about how health care systems produce good results.
Helping ill people is not an easy task. A focus on risk avoidance may unconsciously distract us from this aim. In particular in psychiatry, there is a need to sustain personal relationships with patients to understand their difficulties. The temptation may be to retreat from the anxiety this engagement creates by insisting on the biological nature of their illness. An advantage of this strategy is that it protects those trying to provide care from the pain experienced by those needing support.
'Critical psychiatry' wishes to avoid this objectification of the mentally ill (Double, 2006). The biomedical model of mental illness currently dominates psychiatric practice. Critical psychiatry proposes that psychiatry does not need to postulate that abnormalities of brain functioning are the cause of mental illness. Critical psychiatry may not intrinsically be opposed to a ‘blame culture’ in mental health practice. However, it is likely to avoid defensive practice because it explicitly encourages a focus on the psychosocial origins of mental health difficulties and their ethical implications. It also recognises the expertise of users of the service and works towards a combination of this expertise by experience with professional expertise to create a partnership in treatment. Critical psychiatry also argues for a new relationship between coercion and care that recognises the way values inform clinical decisions.
Critical psychiatry may therefore provide a framework that avoids the worst extremes of defensiveness because it explicitly promotes reflection on practice. Through attempting to counter the reductionism of ‘biologism’ it focuses on the person in assessment and treatment. This approach has the advantage of recognising the potential for human growth and authenticity. I do not want to make too much of the difference from mainstream psychiatry. Of course we can all be panicked by our fears of risk and being blamed. But a deliberate focus on the patient perspective is more likely to make transparent their needs, rather than distort the primary aim of mental health services into the protection of the organisation.
In this chapter I have tried to update the focus of liberatory psychiatry in the modern context of ‘risk’ - not in an exhaustive way, but to appreciate that issues of liberation are still relevant in the modern context of community care. The point of the chapter has been to indicate that critical psychiatry may provide a new synthesis through its analysis of defensive practice. Anti-psychiatry flourished in the counter-culture of the 1960s and reinforced the critique of the oppressive nature of the traditional psychiatric hospital. Psychiatry still needs to be vigilant to create an environment that promotes the independence of people.
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