Copyright © 2007 John Wiley & Sons, Ltd 1: 92–94 (2007)DOI: 10.1002/pmh

A response to the commentaries by the complex case authors

Personality and Mental Health1: 92–94 (2007)Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pmh.14

ADRIAN MORRIS1, SIMON GIBBON1,2 AND CONOR DUGGAN1,2 1Nottinghamshire Healthcare NHS Trust, UK; 2Section of Forensic Mental Health, University of Nottingham, UK

The authors are grateful to the three discussants for their thoughtful comments. As might be antici-pated, their differences in emphasis refl ects their different backgrounds. Indeed, we suspect that if additional commentators from other backgrounds had provided their opinion, there would have been an even greater diversity of views. It would have been interesting, for instance, to have had a user view as we suspect, this would also have provided a very different perspective.

Nonetheless, our failure to come up with an agreed response in such cases must leave both patients and offi cials outside mental health serv-ices either bemused or exasperated. Is our collec-tive failure to come up with a coherent response a refl ection of the different demands made by this case (e.g. the competing demands of mental health services, the criminal justice system, those who support a user’s perspective etc.)? Or is it a refl ec-tion of our failure to meet the complex needs of a person about whom we have both an inadequate understanding and an inadequate capacity to deliver on (or both)? Who knows? We will respond briefl y and selectively to a very few of the issues raised by each of the discussants in turn.

To Dr Rome

Forensic practitioners are generally phlegmatic individuals, having seen it all and (probably) done it all; Dr Rome is no exception. He is generally sanguine about what transpired, suggesting that Mr A exhibited suffi cient mental health needs to support his transfer to hospital, irrespective of the public protection issues. In this respect, he makes two important points: First, that there are is an ethical issue in not offering individuals similar to Mr A an opportunity to avail of treatment oppor-tunities that might either improve their sympto-matic well-being or reduce the likelihood of further reoffending. With this, we entirely concur. Second, he suggests that we ought to have addressed some of his psychiatric symptoms with pharmacother-apy. In this respect, it was remiss of us not to mention that Mr A had been treated with both an antidepressant and an antipsychotic medication while he was in prison. The latter (olazepine 20 mg) was continued while he was with us although dose was reduced to 10 mg: We agree with Dr Rome that drug treatment is underused with such patients, partly because of the timorous approach by

‘Sentenced to hospital’—A response

Copyright © 2007 John Wiley & Sons, Ltd 1: 92–94 (2007)DOI: 10.1002/pmh

psychiatrists, but also because the evidence in support of any pharmacological intervention, espe-cially for those with Antisocial Personality Disorder (ASPD), is weak (Duggan et al., 2006). Finally, Dr Rome makes the point—legitimately (see below)—that ‘. . . neither he nor the mental health system is worse for his experience.’ Unfortunately, this experience cannot be generalised as, if Dr Rome were to visit any high secure hospital in England, he would there fi nd a large number of individuals with personality disorder who are detained against their will ‘for treatment’ so that their risk of further violence will be reduced. Many of these patients believe that they have no treatment needs and therefore actively resist what is offered to them, their sole raison d’etre being to get out of the system that incarcerates them. When this is thwarted, they become understandably frustrated so that they behave violently; this behaviour is then used as evidence for further work. Our intention in being transparent at the outset and allowing the possibility of discharge was to avoid placing our-selves and the patient in an adversarial contest where no one would be the winner.

To Professor Bateman

Professor Bateman takes a different line and cogently argues that it is the patient’s failure to mentalize that is driving his psychopathology. While we agree that the ‘nurture’ element in his case was probably key to understanding him, it is important to recognize that for the most diffi cult forensic patients, it is ‘nature’ that appears to be the more important resulting in them being callous and lacking emotional reactivity—both of which are highly heritable. Do these individuals also lack the capacity to mentalize and if so, should they be treated differently to those who lack these traits and if so, how? However, we agree that this man is not like that and that he has a high degree of ‘emotional reactivity’—perhaps his problem is that it is too high.

There are many points that we might take up in Professor Bateman’s thoughtful account but

let us concentrate on one of his crucial points (perhaps, indeed, the crucial point in this case), namely, that ‘I would not have informed the patient that he would be discharged if he did not engage. I would not expect him to engage.’ While it may have appeared from our brief account that we were intent in setting him up to fail from the outset by specifying a negative outcome, we do not believe that this was the case. The clinical team was clear from the outset (and indeed conveyed this to the patient) that (a) we recognized that he had several diffi culties; (b) the unit was set up to help individu-als with these kinds of problems so that there was a good correspondence between his needs and what was on offer; (c) that we were willing to help, should he wish to avail of it. Professor Bateman interprets this as ‘Specifying a negative outcome from an anticipated interactional stance will not help engagement.’ (p. 87) But, is it a negative outcome if he fails to engage because he chooses not to? Perhaps, it is a positive outcome as he may feel valued in having an equal say in the process. Indeed, the discussant appears to be making this point earlier when he writes ‘He can only begin to develop an understanding of others’ motives if he comprehends what goes on in others’ mind(s). Our recommendation is always to be clear and open about potential changes in treatment and wherever possible to engage the patient in this discussion before a fi nal decision is taken.’ (our italics) (p. 86) Our therapeu-tic approach to any referral is to behave similarly, that is, have a clear and open discussion about what is on offer and our expectations in advance. We saw no reason to change our approach in this instance simply because Mr A had been forced to come to the unit.

To Mr Lock

Mr Lock makes the point that the law on ‘treat-ability’ of those with a psychopathic disor-der . . . cannot be described as being in a satisfactory state,’ We agree. It is telling that he refers to R v. Cannons Park MHRT ex parte A decision—where the Court of Appeal reversed an earlier High Court

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decision of Justice Sedley who found that ‘. . . it was never appropriate under the provisions of the 1983 Act . . . for the patient to be detained in hos-pital for medical treatment for psychopathic disor-der if he or she is not at that point treatable.’

At issue here was if the patient refused to comply with treatment, was she (it was a woman who sought the initial Judicial Review) treatable? Sedley said no but the Justices at the Court of Appeal thought differently (see Baker & Crichton, 1995). They were clearly alarmed that the Sedley decision might encourage others to obtain their liberty by not complying. For instance, to quote Justice Kennedy again ‘Were this to be accepted, patients would deem themselves untreatable simply by withholding their co-operation. That would place the key to the patient being detained in hospital in the patient’s own hands which would not have been Parliament’s intention.’

In this respect, Mr Lock makes the point that if the existence of this option (i.e. the decision not to comply) was more widely understood, it would have a detrimental effect on patient engagement. Here, we fear he is mistaken; this option (i.e. of non-engagement) is already widely understood, both by patients and their legal advisors, and is a card that is increasingly played in contested Tribunals, at great fi nancial cost to the State.

Dr Rome made the point that it was ethically wrong to deny treatment to those who might benefi t from it as it would be wrong to force someone to have a treatment that he/she did not want. Yet, this ‘worst of all worlds’ appears to be the consequence of our current legistation. One of us has recently written that ‘The asymmetrical application of the treatability criterion to those outside hospital compared to those within it led one commentator to conclude dryly that the ‘. . . new treatability test is designed to protect the hospitals from any responsibility towards patients whom they do not want, but provides no protec-tion at all for the patient who does not want the hospital.’ (Hoggett, 1990 quoted in Duggan et al., 2006). The fact that the Courts afford little protec-tion to the patient once he or she is detained sug-

gests that there is an even heavier burden on mental health practitioners to think carefully when faced with the choice of whether or not they should admit someone for treatment.

Mr A—a Year Later

Peter Scott, the father of forensic psychiatry in Britain said that ‘The follow-up is the great expo-sure of truth . . . it is to the psychiatrist what post-mortem is to the physician’; as part of our annual follow-up, the following information on Mr A was obtained from his Probation Offi cer.

Much to the surprise of the Probation staff, Mr A was still in the community and, apart from two minor traffi c offences, he had not faced any other charges. For a period of time, he had resumed taking heroin but latterly has ceased doing so and had volunteered for a methadone maintenance programme and was seeing a drugs counsellor. He has been in three relationships with women, one of which lasted for some months and provided him with a degree of stability. He remained on the Multi Agency Public Protection Panel (MAPPP) Level 3 (the highest degree of surveillance as he was still deemed to be at high risk of reoffending). He continued to meet weekly with his probation offi cer and social supervisor. The former stated that, while he still remained a ‘troubled man’, she believed that there had been gains during his admission and that these had persisted on dis-charge so that he was now more thoughtful and able to take some responsibility for his behaviour.

References

Baker, E., & Crichton, J. (1995). Ex parte A: psychopathy, treatability and the law. Journal of Forensic Psychiatry, 6, 101–109.

Duggan, C., Adams, C., McCarthy, L., Fenton, M., Lee, T., Binks, C., & Stocker, O. (2006). A systematic review of the effectiveness of phamacological and psychological treatments for those with personality disorder. National Forensic R&D Website. www.nfmhp.org.uk/MRD%2012%2033%20Final%20Report.pdf

Hoggett, B. (1990). Mental health law, 3rd ed. London: Sweet and Maxwell.