ATTITUDES TOWARDS THE MANAGEMENT OF 'DANGEROUSNESS' WITHIN MODERN MENTAL HEALTH PROVISION.
By
Chris Wood, Practice Development Nurse
“The risk management process should enable the optimum level of care to be given to a client. Risk management involves the assessment of risk relating to client care, care systems and the environment of care. The calculation of risk must be based on your (nurses) knowledge, skills and competence and you are accountable for your actions and omissions. You should value the process of risk taking … as it will increase your ability to help clients to achieve their potential”. (NMC 2000).
INTRODUCTION
The controversy surrounding the recent publication of the consultation document for the new proposed Mental Health Act has once again focussed attention on the conflicting perceptions of the relative risk posed by mentally ill individuals who may be considered ‘Dangerous’, and what should be done to address their needs.
The general concept of `Risk` has become increasingly complex and high profile within modern society. Historically, incidents which had an impact on the safety and welfare of individuals within society, tended to be either endured or dealt with directly by the victims, or managed by the powers that be with their own economic or dynastic aims in mind, a situation which is often largely still true in poorer parts of the globe (Ziegler 1982). However, within modern western society there is a greater degree of expectation placed on societies` rulers (whoever they may be) that steps will be taken to eliminate risk in all its' manifestations, particularly within a culture that is becoming increasingly litigious. One area of risk which, over the last few decades, has received a particularly high profile is that of risk on the part of the 'mentally ill', both to themselves and others, and the perceived `dangerousness` of this section of society (McMillan 1995).
BACKGROUND.
The governmental position as far as clinicians are concerned appears clear;
`Risk assessment is an essential and ongoing element of good mental health practice... All members of the team, when in contact with service users, have a responsibility to consider risk assessment and risk management ...` (D.O.H. 1999a).
Baly (1994) identified that societies' attitudes towards the mentally ill are largely shaped by the economic and cultural conditions prevalent at the time, consequently perceptions of risk within these areas are viewed similarly. Contemporary treatment of the mentally ill offers a stark and interesting contrast to the past, when analysed against the historical context described by Baly.
Prior to the industrial revolution, the mentally ill were generally tolerated (if not ignored and disenfranchised) within their own communities, indeed the liberal ideas of the 18th century innovators Phillipe Pinel and William Tuke, may not have been considered out of place within modern health care. However, the economic demands of the industrial revolution meant that austere, disciplined, institutionalised 'care' within large purpose built hospitals was considered to be more financially viable, alongside this developed similar austere and paternalistic attitudes towards the mentally ill, the main aim became the isolation of the 'insane' from society in general. This situation remained largely unchanged until about the 1950s, when more enlightened post war influences came to bear (eg more liberal attitudes generally within society, and a greater emphasis on therapy as opposed to custody within mental health services), combined with the introduction of psychotropic medication. This led to more recognition of the rights of the mentally ill and the importance of greater integration into society in order to promote some normality into their lives, (Gelbert 2000). This picture gradually changed throughout the 1980's and 90's, as official figures showed a homicide being committed, on average, every two weeks by ex psychiatric patients and this, together with high profile murders such as those of Jonathan Zito, occupational therapist Georgina Robinson, W.P.C. Nina Mackay, and Lyn and Megan Russel, not to mention incidents of self harm by patients themselves (eg Ben Silcott), brought into question the whole concept of community care of the mentally ill, raising the perception of risk on the part of the general public in this respect (McMillan 1995), and despite certain authors disputing the validity of those official figures (e.g Taylor and Gunn 1999).
The document 'Our Healthier Nation' (D.O.H. 1998), stated that 'It is the job of government to identify risks to health', it also mentions that the public should be made aware of the 'odds' involved in such risks, and that the government should consult independent respected professionals in order to make risk assessments (e.g scientific and medical experts). However, governmental ministers themselves acknowledged that public confidence in services providing care in the community had been undermined by repeated failures (Milburn and Straw 2000), often involving breakdowns in basic communication (D.O.H. 1999b) and (Mahoney 1998). As well as conflicting messages from central government, public disquiet over this issue had been further fuelled by the influence of reporting by the media on this topic, and they helped focus public opinion for better or worse, into one of demanding change from the government (ibid).
When the new Labour government came to power in 1997, mental health was high on the agenda, and with the then health minister Frank Dobson publicly stating 'Care in the Community has failed' (Mahoney 1998), they appeared to be reflecting a greater general perception of risk by announcing a review of existing mental health legislation, with particular emphasis on the wider political agenda of public safety and treatment of 'dangerous patients' in the community who fail to comply with treatment (D.O.H. 1999c), and (Campbell and Sandford 1999).
THE CURRENT SITUATION.
The Government is now in the process of finalising legislation which they intend will address perceived shortcomings in the 1983 Mental Health Act, as far as both community provision and individuals who are currently considered to be suffering from ‘untreatable’ conditions such as certain types of personality disorder are concerned. It is proposed that in future there should be one path to compulsory treatment whether in hospital or the community, called the `Mental Health Act Order`. Essentially the new Act will replace the 1983 Act wholesale although it remains to be seen what, if anything, will replace current sections such as `4` (emergency admission) and `5(4)` (the Nurses` holding power). Within the new act it is likely that `assessing` mental health professionals will have to give written reasons for not using compulsory powers. Current provision that no-one shall be treated as suffering from mental disorder by reason of sexual deviancy or addiction to alcohol or drugs in isolation, is likely to be abolished. Built in review contingencies such as `Mental Health Tribunals`, and a new broader definition of mental illness to include `personality disorder` are also featured. All this is with a view to not only supposedly protecting patients' rights, but also in order to help protect the public by avoiding issues regarding `treatability`. As can be imagined, the new Act as it is currently envisaged is fraught with controversy and Human Rights issues, but is still however awaiting Royal Assent (having recently finished its’ consultation phase), and is unlikely to become law until around 2004/5.
THE DIFFERING VIEWPOINTS.
Thompson (2000) argues (not unreasonably) that a balance needs to be struck between maintaining patients rights and protecting potential victims of dangerous behaviour. Indeed, the situation regarding the treatment of the potentially dangerously mentally ill is the subject of many strongly held and often conflicting views. There are several authors and groups who have voiced concerns and fears over issues surrounding patients rights. Barber and Catcliffe (1999) argued for the importance of an 'ethical perspective' in drawing up any legislation to deal with this issue i.e. consideration of human rights legislation, and the inclusion of rights including advocacy, appeal mechanisms, confidentiality and quality of care. The theme of including patients, carers and advocacy groups in drawing up risk management and treatment protocols, is one promulgated by various sources, e.g. authors such as Perkins and Pepper (1998) and pressure groups such as MIND (Pedlar 1999), discuss the concept of involving 'Users' to instil a feeling of shared ownership of risk management protocols through mediums such as 'Patient Councils' in planning policy, thereby promoting the likelihood of user observation of subsequent risk management protocols. The involvement of user groups in risk management formulation would undoubtedly offer a more collaborative and balanced view in this respect.
In contrast, Campbell and Sandford (1999), identify that many observers feel that the pendulum in favour of patients rights has already swung too far under the existing 1983 Mental Health Act, and would incline towards a more custodial emphasis in risk management. Quite apart from the more sensational platitudes of the mass media, many professionals have also raised legitimate concerns regarding issues of safety in this respect. Morrall (1998) for instance, argues that services should be organised to ensure maximum safety for all concerned (public, users etc). It is indeed the concept of safety that is at the heart of risk management, and is surely the single most important consideration in this issue.
The dichotomy in the 'carer-custodian' role on the part of those charged with making clinical judgements in risk management, particularly psychiatric nurses, is reflected in concerns raised by professional bodies such as the Royal College of Nursing, in particular regarding the adverse effect on therapeutic relationships with clients who may have been forcibly detained due to their mental state. Their concerns centre around the potential conflict this may cause nurses although not, apparently, against the legislation itself (Munro 2000). Great skill and judgement has always been necessary on the part of nurses in order to successfully balance this dual role, particularly as such patients may be nursed in isolated community units with minimal multi-disciplinary support, as well as in order to justify public confidence in this area of risk management (D.O.H. 1995).
The government have acknowledged that in order to address this issue adequately the necessary resources will have to be made available both to recruit, train, and supervise staff (one example is the increasing numbers of assertive outreach and crises intervention teams), as well as to provide enough beds to cope with probable increased demand, especially as the new legislation makes provision for patients who might commit an offence, (D.O.H. 2000) and (Clark 1999). Specific commitments have already been made by the government through the Mental Health National Service Framework (DOH 1999d) for example; Standard 1 talks about improving health promotion towards, and reducing discrimination against, mentally ill offenders by the introduction of ‘service models’ that promote the interests of ‘vulnerable groups’ such as prisoners, and Standard 5 describes the importance of increasing the numbers of appropriately staffed ‘secure beds’ (DOH 1999d).
UNTREATABILITY?
Depending on the point of view of the particular commentators (often from the same governmental department) does one assume that all patients subject to these orders and having committed such offences, are all suffering from untreatable personality disorders (psycopathy) (D.O.H 1999c), or can we (probably more reasonably) expect that many of these offences are committed by persons suffering from other forms of mental illness (e.g Schizophrenia) who are victims of failures in care on the part of statutory services (D.O.H 1999b)?
As far as the origins of particular conditions are concerned, various authors have looked at both biological and genetic factors (Kokkonen et al 1998) and environmental factors (Dalgard 1996) in order to predict later mental ill health, each showing correllations between adult mental state and these developmental factors (respectively). However, in order to manage the presenting risk, statutory services throughout the western world have chosen to screen possible perpetrators using individual risk assessment criteria generally looking at an individuals previous risk factors in order to compile individual treatment programmes, (Timmerman et al 1998). Many have looked at risk factors in detail (Doyle 1998), identifying specific indicators of risk and relapse (e.g anniversaries) as well as different types of risk area (deliberate self harm, harm to others etc). This philosophy, though systematic and well intentioned, is largely reactive. Others have attempted to take a more proactive stance to risk management, with a view to prevention by catching `at risk` individuals as early as possible in the first stages of mental illness to institute effective treatment (or at least 'containment' in the case part of 'untreatable' personality disordered individuals), (Kendrick 1999). One study in the US for example, has presented strategies for recognising emotionally maladaptive children at risk of developing adult mental ill health, (Parens and Kramer 1993).
RISK ASSESSMENT.
Despite the fact that risk management practices largely concentrate on individuals, certain groups within society have been shown to be at higher risk of harming themselves or others. A good example of this, is when one considers societal sub-groups who have been subject to discrimination on the part of society as a whole. Several authors identify the increased risk of depression, self harm and suicide that young adults of both genders (but particularly males) are subject to upon the realisation that they are homosexual or bisexual (Fergusson et al 1999) and (Elze 2000). Elze further acknowledges the need to consider the attitudes of both family and community, as well as individual factors, when assessing risks within such a group.
It is well documented that young black males within British society, are subject to much higher diagnostic rates of serious mental dissorders such as schizophrenia and personality disorder and, subsequently, increased risk of violent conduct related to such diagnoses, (D.O.H. 1992). Here, cultural issues surrounding integration into society, and perceptions of race and racism need to be examined in order to address the underlying reasons as to why this should be the case, and not just the negotiation of the presenting overt risk factors.
The potential complexities of any form of risk should therefore be reflected in the tools used to assess those risks, and risk assessment tools need to be as robust as possible, taking into consideration not just behavioural antecendents, but also cultural, environmental, social, physical, familial and financial risks, as well as the presenting psychological and psychiatric factors. Recent authors call for a participatory approach, in which the different stakeholders are consulted at early stages within the risk assessment process in order to "characterize" risks, this is aimed at taking into consideration the views of all interested parties so all the potential dimensions of risk can be reviewed (Amendola 2002). Indeed this would go a long way to offsetting any ‘knee jerk’ response to high profile incidents (see above) by initiating a more considered all encompassing ownership and responsibility as far as the risk assessment process is concerned, regardless of specific tools used. The importance of all parties signing up to this process therefore is self evident, but there also needs to be a commitment on the part of managers and those that hold the purse strings to this issue, for example good avenues of communication between senior management and practitioners to avoid any discrepancies in the perception of the importance of this subject, and in particular provision for adequate risk assessment training (Beale et al 1999).
LITIGATION.
The use of rigorous and systematic research methods should be used to inform both practitioners and policy makers as to the most effective methods of risk management (Slovic et al 2000). However, in an increasingly litigious society, it is hardly surprising that policy effecting such a potential risk to public safety as is care in the community, is often driven by the spectre of legal action. This problem has already been identified by many (mainly American) authors (Calfee 1998) and (VandeCreek and Knapp 1994), and whilst it is readily apparent how this can lead to unhelpful 'defensive' practices on the part of practitioners, (eg denying discretionary leave to formally detained patients), it can also be a positive influence in compelling practitioners to more carefully scrutinise relevant areas of care, thus ensuring effective therapeutic risk management protocols are put into place.
The fear of litigation can however, be such that employers themselves stifle considered professional clinical judgements on the part of practitioners, by imposing organisationally driven procedures designed purely to limit the threat of financial loss. Another legal consideration to bear in mind is that it is not only members of the public who may choose to resort to law but also clinicians themselves. Over a decade ago, an increased willingness on the part of nurses to undertake legal action against patients who had assaulted them had already been identified (Thomas 1991). Further financial strain may be incurred by organisations, as patients themselves seek greater recourse in law, and increasingly for services failing to protect patients from some of the consequences of their own (patients) actions.
CONCLUSION.
The closure of the old Victorian Institutions and wholesale movement of their patients into the community, often without adequate community provision being made, has indirectly led to many dangerous and even fatal incidents which have served to focus the minds of all sections of society in this respect. How this perception is formed, particularly on the part of the general public and governmental policy makers, and the validity of that perception, is open to question, but there seems little doubt that as far as the public are concerned their collective opinion is often shaped by the media (who generally sensationalise in order to sell newspapers or improve viewing figures). In turn, governmental response and policy is largely influenced by public opinion with an eye on the political vote winning agenda, though not necessarily with the best interests of all concerned at heart.
Perceptions can be changed though, and in order to do this those charged with the task of risk management need to regain the trust of both public and service users. Efficient systems of risk assessment which adopt proactive and all encompassing principles, examining issues such as early recognition of risk and at risk groups, combined with effective systems of communication across health disciplines, will go much of the way towards achieving this. The government and health service managers also have a responsibility to both adequately resource risk management itself and research into the epidemilogy of risk, as well as the provision of clear, accurate guidance in policy and legislation, regardless of popular opinion, potential litigation, or risk to their own professional interests (a tall order no doubt).
Finally, attention needs to be paid to public education regarding these issues by using objective data. The successes of good risk management are rarely publicised, as are honest explanations of the limitations of risk assessment, in that it carries by definition, an inherent degree of risk, (life itself containing a degree of risk for us all). In addition, common public prejudices held against certain `at risk` sections of society e.g. non-whites, homosexuals, and the mentally ill, need to be addressed. Ultimately this is in the best interests of all sections of society.
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