Fear and freedom

It is hard not to be intrigued by the tale of a man who kills a
mate and then fries and eats his brains. But, as he was a
psychiatric patient at the time of the killing, “who let him
out?” is the question that most people have been asking. It
later turned out that Peter Bryan had killed before and had spent
time in a secure hospital before his release back into the
community.

The case of the “cannibal”, as Bryan has become known,
has reignited the debate about care in the community for mental
health patients. Few people can believe that professionals could
have deemed him well – and safe – enough to be let out
of hospital twice. The public wants to know just how safe care in
the community can be if mistakes as grave as these still
happen.

It hasn’t helped that the case of Bryan followed on the heels
of another killing by a mental health patient. John Barrett, who
like Bryan was a paranoid schizophrenic, stabbed a man to death
after being allowed leave from a psychiatric hospital. He had also
been violent before. Again the question has been asked: why
didn’t the staff involved detect the risk he posed to
society?

These two cases are not isolated examples of homicides by people
with diagnosed mental health problems. Nine per cent of killers in
England and Wales have been in contact with mental health services
in the year preceding the offence, and almost a fifth have had
contact at some point.(
1)

In the past 10 years there have been more than 150 independent
inquiries into homicides carried out by psychiatric patients, and
the findings seem strikingly familiar. The evidence often points to
a catalogue of errors by the mental health services involved,
usually due to poor communication, inadequate risk assessment or
lack of face-to-face contact with service users.

One of the most well known inquiries followed the death of Jonathan
Zito, who was stabbed to death in December 1992 while waiting for a
London tube train. The report into the care of his schizophrenic
killer, Christopher Clunis, revealed that three months before the
attack Clunis had been discharged from psychiatric hospital into
the community.

More than 10 years later, what is still going wrong?

Part of the problem is that many of the old institutions have been
shut without enough replacement provision in the community, says
Michael Howlett, director of the Zito Trust. The 150,000 beds that
were available in the 1950s have now been reduced to fewer than
33,000 and the remaining psychiatric hospitals are buckling under
the strain.

“You have to be pretty ill to get into hospital and there is
a risk of being discharged before you are ready. This puts even
greater pressure on community-based services,” says
Howlett.

“We feel there are people in the community who
shouldn’t be there. They should be back in hospital. They
have been abandoned or forgotten or gone off the radar screen and
not adequately followed up. Even if they were known about, it would
be almost impossible to find them any hospital services, because
they are overstretched.”

That mental health services are at crisis point is not in itself a
revelation. For years the sector has been under-funded, and despite
mental health being declared one of the government’s top
three health priorities, funding has lagged behind other
areas.

About one in three people who approach services are turned away.
Without the help they need, their condition often deteriorates
until they become seriously unwell.

A more preventive strategy is vital if care is to get better, says
Tony Zigmond, vice-president of the Royal College of
Psychiatrists.

“You won’t prevent tragedies by targeting tragedies. If
the aim is to reduce the number of homicides, general improvements
in mental health services in the community and in hospitals will
achieve this,” he says.

But while any homicide is one too many, it is important to keep a
sensible perspective on the number carried out by psychiatric
patients. Every year there are about 50,000 detentions under the
Mental Health Act 1983, and most people are subsequently discharged
back into the community. 

“You are 10 times more likely to be killed by your employer
than by someone with a mental illness,” says Zigmond.
“There are 400 deaths due to corporate manslaughter every
year and just 40 by the mentally ill.”

It’s just that when such homicides happen, they tend to reach
the headlines. Staff find themselves pilloried for their mistakes
which, with hindsight, seem avoidable. Surely this climate of fear
must make staff reluctant to take risks?

Absolutely, says Zigmond. “That’s why the number of
people detained has doubled in the past 20 years, though
there’s not been a doubling in the amount with mental
illness. People are being detained more readily and kept
in.”

L

earning how to assess the risk that a patient poses, either to
themselves or to others, is a fundamental requirement for staff
working in mental health services. However, that doesn’t mean
training is always available or accessible. Even when it is,
practitioners often find they cannot spare the time away from
clinical duties.

Steve Morgan runs a practice development consultancy and trains
people on risk assessment. In an attempt to tighten up their
procedures and cover their backs, organisations are increasingly
turning risk assessment into an administrative, form-filling
exercise.

“The narrow focus on paperwork is a knee-jerk reaction to
what is portrayed in the media. But making sure the paperwork is
done distracts from the real assessment of risk in day-to-day
work,” he says.

Morgan adds that the fear of getting things wrong – from
organisations and practitioners – ultimately has a
detrimental impact on service users.

“They say that when stories hit the headlines, trusts become
more negative and restrictive. Practitioners are worried that if it
happens to them they will be on the front page. A substantial
number of people are not receiving the services they need and
deserve because practice is being driven by a fear of things going
wrong.”

If services are no longer of benefit to users, then the users stop
coming to them. And if users stop accessing help when they need it,
their mental health is likely to suffer and the risks
increase.

The system may not be working as smoothly as it could, but are
things set to change with new mental health legislation? Not if the
draft mental health bill goes through parliament, assuming that it
is revived in its current format in the next parliament.

“It could make the situation worse,” says Paul Farmer,
chair of the Mental Health Alliance, a coalition of more than 60
mental health organisations campaigning on the proposed
changes.

For a start, the way the bill is framed – particularly with
its wide definition of mental disorder – could lead to more
people being subject to its powers. Receiving help early reduces
risks, but if an individual thinks they may be locked up, they will
be reluctant to seek help.

In addition, the bill is seen to disproportionately emphasise the
danger posed by people with mental health problems. Under the
proposals, people who are considered dangerous, such as those with
personality disorders, could be locked up indefinitely –
despite evidence suggesting that between 2,000 and 5,000 people
would need to be detained to prevent just one homicide.
Again, fear and society’s negative perceptions of mental
illness, are likely to drive people away from the help they
need.

The joint parliamentary scrutiny committee that analysed the bill
has made it clear that public protection should not be allowed to
dominate reform of mental health legislation.(

2)

But in light of the outcry over the recent homicides, the
government may not heed the warnings.

To this end, Farmer is concerned. “The danger is there will
be a knee-jerk reaction on the back of these two cases, which are
extremely rare if you look at the number of people with mental
health problems who pose absolutely no risk. We have to frame the
legislation to meet the needs of many.”

Exactly what shape the legislation will take remains to be seen. Up
until now the government has remained determined to focus on public
protection, despite calls for mental health legislation to be
primarily concerned with patients. It is to be hoped that any
amendments to the bill are written before anyone else is killed
– otherwise one dreads to think what draconian measures they
could contain.

(1)

Five-Year Report of the National Confidential Inquiry into
Suicide and Homicide by People with Mental Illness, Department
of Health, 2001

(2)

Report of the Joint Committee on the Draft Mental Health Bill,
2005, from www.publications.parliament.uk/pa/jt/jtment.htm

‘Good support means everything’ 

Martin Reynolds, 43, suffers from schizoaffective disorder. He has
had three hospital admissions – an eight-month stint in 1995, three
months in 1996, and a week in 1997. In between admissions he has
lived in the community. 

“In 1995 when I first came out of hospital, care in the community
was terrible. I was dumped in a flat on the worst housing estate in
the area and told to get on with it. It was not conducive to my
mental health at all,” he says.

During this time his home was broken into eight times and he was
abused and threatened in the neighbourhood. As for care from mental
health services, he had infrequent appointments with a psychiatrist
and none with a social worker or community psychiatric nurse
(CPN).  

But he says that the NHS has improved in the past 10 years and he
now has weekly visits from a CPN. At last he feels that he is
receiving enough support. And what does it mean to him?

“Good support in the community means everything. I made a couple of
suicide attempts in the past and it’s possible that if I didn’t
have enough support self-harm might be an option again.”

As for the recent hype around homicides by people with mental
health problems, he thinks that the public could
misunderstand.

“I wouldn’t like people to get the impression that all people with
a diagnosis are a risk to the public. I’m not a threat to anybody.
I’m a very peaceful man.

“He thinks that the public – and the government – should heed  the
statistics showing the tiny percentage of people with mental health
problems who commit crimes.

He adds: “I hope the government doesn’t round them up and get them
in hospital when there is no need for it.”