Community and forensic psychiatry
Community and Forensic Psychiatry
Psychiatry is a speciality that was greatly undermined. This specialty was considered to offer a form of self control and management, whilst not being able to offer any form of treatment for mentally ill patients. This SSC has allowed to me to understand, explore and make my own opinion on this specialty. In the past, diagnosis made by psychiatric doctors was said to be vague and arbitrary (1) hence people did not consider psychiatry as a branch of medicine. I completely disagree with such close-minded statements. Psychiatry is a specialty, where medicine is applied in greater depth with practical communicational skills, to achieve the best health outcome for mentally ill patients.
What is Psychiatry and what happen during a consultation?
Psychiatry is a branch of medicine intended to explore, study and treat mental disorders. The approach taken for diagnosis in this specialty is very detailed and different in comparison to other specialties like gastroenterology and cardiology, where the diagnosis is mainly pathological. Psychiatric assessment normally begins with a mental status examination (MSE), which is a part of the clinical assessment in psychiatric practice. This assessment is a thorough description and observation of a patient's current state of mind, appearance, behaviour, attitude, mood, perception, cognition, insight, speech and judgements. After the MSE, the psychiatric takes a complete history, which is very different to a normal history taken by a General Practitioner. The psychiatric starts the history take with personal identification to confirm the patients details, then moves on to the source of presentation, main complaints, history of the presenting complaints, past history consisting of (psychiatric history, medical history), family history, past medication, developmental history, social history, drug and alcohol history, forensics history, pre-morbid personality history and then a summary considering any other contributing factors to their complaints. This allows the psychiatric doctor to make his diagnosis and decide on the treatment for the patient. Psychiatry can offer a variety of treatments, which include medication, psychotherapy and Trans-cranial magnetic stimulation. These treatments can be received as an inpatient or outpatient depending on the functional status of the patient and severity of the disorder. (2) (Appendix visit 2)
Psychiatry has many subspecialties or separate theoretical approaches to different mental disorders. The following are some of the subspecialties. (3)
Addiction psychiatry: Is based on providing treatment and adherence for alcohol, drug, or other substance-related disorders and dual diagnosis of both drug abuse and mental disorder.
Biological psychiatry: This subspecialty aims to understand the biological function of the nervous system and the reasons that can cause mental disorders in the biological terms.
Community psychiatry: An approach aimed to provide and practice psychiatry in community mental health services.
Forensic psychiatry: an approach linking the law with psychiatry
Military psychiatry: Is a subspecialty providing treatment for military workforce suffering from mental disorders due to warfare or military lifestyle.
Subspecialty of interest (Forensic psychiatry)
This is subspecialty is very appealing, because of the challenges that it contains. The mental health and legal professionals in forensics take on an inspiring challenge in applying their knowledge and expertise to the criminal justice system. These professionals perceive and comprehend the nature of the forensic issues found in the law-mental health interface, whilst applying the criminal justice system. (4), (5)
History of Psychiatry and Law
Forensic psychiatry is exceptionally advanced compared to other subspecialties of psychiatry and will continue to advance. The modern forensic psychiatry left many significant development traces that can be dated back to the 17th century, when the insane offenders were ordered to be sent to Bethlem for detention. Most of the insanity defense rules were investigated and put place in the 19th century between 1800 (Hadfield's case) and 1843 (McNaughton's case). Hadfield is a person who believed that the second coming of Christ would be brought about by killing the King (George III). These insane thoughts were due to several severe attacks to his brain during the battle of Tourcoing. Hadfield has sacrificed his life for his country and people didn't want to see him hanged, as he was well known for his bravery. Lord Kenyon investigated the matter and the verdict was that Hadfield was "not guilty; he being under the influence of insanity at the time the act was committed". His verdict was questioned in regard to his decision of the origins of the phrase “not guilty by the reason of insanity”. This has resulted in the parliament considering similar criminals to go free, provided jury decision "not guilty by reason of insanity" should be remanded in custody until granted a royal pardon under the Criminal Lunatics Act 1800. This act also puts limits to the use of defense of insanity to indictable offences. The next case was McNaughton's case, which was that he didn't know right from wrong. Daniel McNaughton shot one of the British Prime Minister secretaries, in an attempt to kill the Prime Minister, believing that Prime Minister was conspiring against him. The court has discharged McNaughton “by reason of insanity”. This matter was scrutinised by the public and has resulted in Queen Victoria to order the court to develop a stricter test for insanity. The court made a rule known as “McNaughton rule”. This rule is only applied by the jury after hearing from the 2 medical doctors confirming his state of mind. The stated that "at the time of committing the act, the accused was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing or, if he did know it, that he did not know what he was doing was wrong." This rule became the standard rule for insanity in the UK and USA. (9)
McNaughton's and Hadfield cases have led to the Mental Health Act. Most of the mental disorder offenders are treated under the common Law and the Mental Health Act 1983 and 2007 allowing admissions of offenders for treatment under “sectioning”. Also, the Human Right Acts 1998 states that provision for the detention of person of unsound mind. (5)
Also, In the 1960s “judicial decisions on permissibility of psychiatry with the condition of depth understanding and acknowledgment of law” allows forensic psychiatry to work along court officials in coming to a decision. This development joined and refined the specialty with growing fame, which was marked by the formation of prominent professional societies (The American Academy of Psychiatry and Law in 1968). These societies have elaborated the forensic specialties by creating sophisticated training programs at the doctoral and postdoctoral levels (brigham & Grisso, 2003). Modern forensic psychiatry is dignified by their effective understanding of legal issues and the practical importance of their practice in law and prisons. (8)
What is forensic psychiatry?
The definition of ‘forensic' simply means related to, or with concern to, or used in courts of law. A forensic psychiatrist's job mainly starts with a MSE (mental status examination) to provide a psychiatric report for the court on the mental state of the offenders assumed or suspected to having a mental abnormality. If the offender is mentally ill, then the forensic psychiatrist will be then expected to offer and arrange treatment for the mentally abnormal offender where appropriate. The forensic psychiatrist is also expected to comment on the risk of dangerousness, which also can be requested by the parole board for safety of inmates serving along the offender and whither they can be released back to the community risk-free, after serving their sentence.(5), (6)
Forensic psychiatry is very diverse. A Forensic Psychiatric normally works in the following environments: high secure unit, medium unit, low unit and specialist secure units, forensic community psychiatry, court diversion, probation liaison, forensic psychotherapy, forensic learning disability, forensic adolescent psychiatry and expert witness. (7)
Psychiatric treatment in prison
Forensic psychiatrics do not provide psychiatric treatment in prison, but they treat prisoners once referred to a high or a medium secure unit (i.e. River House Bethlem). The prison is not a place for seriously mentally ill prisoners as stated in the report of the Reed committee department of Health and Home office, 1992 and they must be transferred and treated in a secure unit to receive treatment. Despite the ethical difficulties in treating murders and potential killers, as a doctor, medical care must be provided to the same equal standard as with the health service outside the prison and secure units.
Dealing with prisoners is very risky and alarming, because you don't know what to expect, but the majority of prisoners do have mental disorders due to their surrounding environment and they are in need of treatment. A study conducted by the office of National Statistics using a systemically described distribution of mental disorders in prisoners. The study shows only 1 in 10 prisoners showed no evidence of any mental disorder and no more than 2 out of 10 had only one disorder. The norm in prison is having multiple mental disorders. 39-75% of different sample groups consisting of male, female, sentenced and un-sentenced are diagnosed with high neurotic disorders in comparison to only 14% in the community. Specifically, it has been found that women generally have higher scores on the neurotic scale than men. Most prisoners need psychiatric treatment, as the majority of the population in prison are alcohol and drug dependent. Another study conducted in Cardiff providing forensic psychiatric service. In the study 60 inmates participated, 81% have been charged with serious offences. There ages range from 15 to 45 years old (average age 28 yrs old), 23% were young offenders. The following mental disorders were found:
Drug addiction 14
Adjustment reaction 9
Major depression with psychotic features 1
Bipolar affective disorder - manic 1
Drug-induced psychosis 3
Alcohol dependence syndrome 4
Mild mental handicap 1
Post traumatic stress disorder 1
Personality disorder 2
This study also suggest that most prisoners will have some sort of a mental disorder during servicing their sentence , therefore most prisons should have access to some psychiatric services to treat them. (10)
Problems in prisons
The merging effects of committing a terrible offence or being arrested and charged, separated from the normal surroundings, imprisoned and facing the uncertainties of trials and sentencing, increases stress, tension and feeling of dysphoria and depression. These multi-factorials and a poor prison regime can lead many psychological reactions and behavioural changes that doctors will be asked to deal with, these include: (10)
Suicidal rates are very high in prisons and continue to increase. These high rates in prison are associated with the first few stressful weeks on remand, long-term imprisonment and committing violent or destructive offences. The high suicidal rates seem to be associated with isolation, guilt, remorse, depression and despair. The unfortunate thing is that prisoners who are at risk of suicide have characteristics indistinguishable from other prisoners, making it virtually impossible to determine which one of the prisoners maybe at a higher risk of suicidal attempt; therefore it's very difficult to give psychiatric treatment and support to the right prisoner at the right time.
Prisoners may refuse food and sometimes drink. Two forms may be recognised.
A minority, who are seriously mentally ill, refuse food as well as any form of fluid. They are characterised by generally by being unable or unwilling to give a reason. Those types of patients require urgent transfer to a psychiatric hospital.
A majority, who use the food refusal in an argument with the authority, will not have serious psychiatric disorder. Some will have severe personality disorder and one or two maybe be psychotic or depressed. Prisons have a routine of having all prisoners who refuse to consume food or fluid to be psychiatrically assessed so that those who are mentally ill can be identified and treated. Those who are normal usually respond to counselling and support. Rarely, a determined normal inmate will starve to death to make a political point.
Prisoners cut or burn themselves (i.e. superficial cuts and burn with cigarette ends) in reaction to feelings of tension and despair. The level of tension is considerably high and self-mutilation can be adopted as an almost infectious quality as the behaviour spreads in the institution. The features to characterise those prisoners are normally emotional instability and immaturity.
Due to the high level of tension, sleep disturbance is common and lead to request for sedation. Prison doctors are likely to be pressured by inmate, especially by the personality disordered or those with a history of drug abuse. This requires a considerable judgement to get the right balance between over and under prescribing as sedatives can be harmful.
Forensic psychiatry is a very interesting field of psychiatry with many relationships and links to other professions. Forensic Psychiatry has allowed us to understand the causal relationship between mental disorders and crimes. As well as providing us with protection by identifying those mentally ill patients with high risk and dangerous in being in the community or even in prison. Whilst providing care for them and giving them the treatment and therapies they need to prepare them back to the community. Forensic psychiatry has contributed a lot to our society and to the law system protecting those who are unfit to plead because of their mental disorder. This is a very exciting career because every case is unique with unique challenges and unique treatments.
1. Visit to Thames Ward, River House, Bethlem Royal Hospital.
Contact: Dr Peter Pierzchniack
The River House is located in Eden Park in Bethlem hospital. The institute is a medium secure forensic rehabilitation centre, with medium security and air vacuumed lock doors. This institute is mainly for offenders, who have committed a violent crime due to a mental disorder, but some are just mentally ill patients that can impose a risk in the community and cannot be managed in care homes or low secure units. All members of staff had keys and radio mobiles to communicate with each other and were equipped with an alarm button in case of emergencies. There are signs everywhere showing all the security procedures to follow at all times (i.e. lock the doors after use etc).
On arrival at 10:00am, we met with Dr Pierzchniack. After introducing ourselves he took us on a tour around the building and told us a bit about the history and background of the building. The River House contained many rooms full of facilities to keep the patients fit and in best form mentally, physical and socially. The facilities available for patients range from sports hall, gym, arts room, music room etc. The aim of having all these facilities according to Dr Pierzchniack is to keep them pre-occupied throughout the morning as well as preparing them back to the community.
At 11:00, Dr Pierzchniack invited us to attend the clinical review meetings to review all the patients in the ward (Thames Ward). The clinical team consists of: a forensic psychiatric consultant, a psychiatric registrar, clinical psychologist, occupational therapist and a social worker. The first patient we met was a 39 year old, Black African male suffering from schizophrenia. He was an offender that set fire on a pub's door because voices in his head told him to do so. In the review meeting the patient looked well and was showing progress. He progressed from the red zone to the amber zone, which are scales used in the clinic to show progress of the patients behaviour, adherence and interaction with other patients and staff. Being in the green zone gave him access to more facilities and was granted an “unescorted leave”, which simply means he can go to the hospital shop and buy what he needs unescorted. Also, in the meeting Dr Pierzchniack got a letter from the ministry of justice requesting for him to be escorted at all time, as he needs to be sent back to Nigeria. Dr Pierzchniack handled the case in a very inspirational way, controlling and managing the situation and offering the patient re-assurance to prevent the patient from breaking down and worsening his condition. The second patient we saw was a 21 year old; Black African Male that also had schizophrenia, drug addiction and behavioural issues. He has continuously stabbed a 14 years old kid in the bus several times and taking his eye out. In the review room the patient had a disciplinary hearing due to attacking a member of staff. The patient didn't show any progress and he continuously play-fights with other patients, causing a lot of chaos in the ward. He was also tested positive for drugs, which means he managed to smuggle drugs in the medium secure unit without anyone noticing. This raised issues regarding security and the checks performed on patients and visitors. He was moved from amber to red zone, therefore has lost access to some facilities and cannot leave the ward.
We also visited a patient's room. The room was very clean and tidy and was full of health and social care books and past papers, as he was preparing for June exams. The patients in the unit also receive education during their rehabilitation to allow them to come back to the community with some qualifications to get jobs.
“Reflection is an important human activity in which people recapture their experience, think about it, mull it over and evaluate it. It is working with experience that is important in learning' (Boud, Keogh and Walker 1985).”
In the River House we had an exceptional experience, because we got a true insight into psychiatry. Most patients in the community are stable and currently coping with their condition. In the River House some patients were extremely psychotic and I felt privileged to see how the team managed them and even break bad news to them. Even though the building was secure and safe, I still felt unease about the security, because I expected the building to have at least a security team on patrol to make sure the health care team and visitors are safe at all times, as these patients are unpredictable yet this was not the case. The learning experience that I gained from this visit is that all situations are manageable and you need a range of communicational skills to take control. The way Dr Pierzchniack managed to break bad news to a mentally ill patient and still keep the patient calm was very inspirational.
The River House didn't feel secure, even though things ran smoothly and everyone looked comfortable and safe in the building. As a visitor I still felt uneasy and I think they should have had a security team on patrol just to re-assure visitors that everything is under control. Another alarming thing is when a patient was positive in his drug test. This simply means that there are flaws in the security system and they should increase the amount of room searches and full body searches of family members, staff and visitors. Other than that, the building was suited for its purpose and the facilities were really appreciated by the patients as they all strive to get to the green zone to get full access to all the facilities.
2. Visit to the Assessment and Treatment team, North Lambeth Community Mental Healthcare Team (CMHT), 190 Kennington Lane
Contact: Dr Ahmed
At 9.00am we arrived at the clinic, we were introduced to Dr Ahmed, and he briefed us of what we are going to do in throughout the day. The unfortunate news for me and my clinical partner was that they had a business meeting with the chief executives of the PCT. We attended the meeting with the rest of the psychiatry community team which consisted of: psychiatry consultant, psychiatry registrar, Training doctor (ST1), Rapid Response Team, Occupational therapist, psychiatry community nurse, social worker and receptionist . The chief executives questioned the services provided by the community clinic; each member of the team explained the progress they made with patients in the community and the importance to continue their service. The team also suggested adding a new role in the team to deal with benefits and finance claims, as they have noticed that most of mentally ill patients need support, in that aspect.
The clinic didn't have many appoints booked on that day, but luckily we had a chance to attend two consultations. The first patient was a 42 years old Asian-Indian lady who was suffering from post traumatic stress disorder. The patient had lost her job due to violently abusing another colleague. The patient is now requesting a doctor's note to apply for a disability allowance due to her PTSD. The second patient was a 25 years old Black Caribbean female, suffering from schizophrenia and boredom. The patient came in expecting the PCN to get her a job immediately due to her increasing boredom. The PCN was trying to be helpful and tell her all the different service (i.e. job centre) to help her to find a job. The patient didn't want to hear about services but wanted a job immediately and was losing her patience with the PCN. Dr Ahmed managed to control the situation using his communicational skills by asking simple questions like “what would you like to do in your spare time” and lead the conversions slightly to direct her to the correct services. But, we didn't get the chance to interview any patient, as they all refused to talk to us.
The rest of the day we spent with the RRT, but we didn't receive any referrals. Therefore, we spent the rest of the day reading previous referrals.
I think we were really unfortunate that day, as we didn't get to see as many patients as we hoped, but overall the visit was great. The learning experience here is how the team worked together to provide the healthcare needed for the patients in the community. The team supported each other, consultations in that clinic weren't just attended by a doctor, the doctor was accompanied by team consisting of a PCN, OT and a social worker. They all use their expertise and knowledge to solve all the issues the patient has and give the patient support adhering back to the community, and this leads to positive health care outcome.
The teamwork in the clinic is great. The only problem was that there was no one that could help the patients with their financial support; therefore they needed a benefits/financial officer in team. The team made this query with chief executives from the PCT in the business meeting and awaiting the fund.
3. Visit to St Thomas' Hospital Adamson Centre For Mental Health Ground Floor, South Wing, Block 8.
We started at 8:15am. The day started by Dr Davies briefly explaining to us the outline of the morning and how many patients he was going to see. The first patient was a 43 years old white female, suffering depression. She came to see the doctor for a 3 months regular check up. The patient also needed re-assurance regarding sleeping pills because she took her brother's sleeping bills. The second patient was a 51 years old South-African white male, suffering from PTSD but didn't want to share his experience with us and wanted to keep confidential between him and his doctor. He also, allowed us to interview him and practice our interviewing skill in taking a psychiatric history. Patient 3 was a 65 years old sufferer of bi-polar disorder and OCD in documenting historical events and events in his life. The patient was very friendly and interactive. He made sure everyone was involved in the consultation and enthusiastically shared a bit about his career and his past.
I felt that consultations in the scrutiny clinic were general and more like a GP consultation but more concentrated on mental health. The learning experience was mainly the communicational skills and the psychiatric history take. The consultations normally start with Dr Davies asking an open question, allowing the patient to talk about his/her concerns. Then Dr Davies takes a Psychiatric assessment normally beginning with a Mental Status Examination (MSE), which is a part of the clinical assessment in psychiatric practice. This assessment is a thorough description and observation of a patient's current state of mind, appearance, behaviour, attitude, mood, perception, cognition, insight, speech and judgements. After the MSE, Dr Davies takes a complete history, allowing him to make his diagnosis and decide on the treatment for the patient. Observing this consistent process allowed me to memorise the procedures followed in a psychiatric consultation.
There isn't much to improve as the clinic runs smoothly and is well organised in serving its purpose. The only suggestion that I would like to add, is to keep in contact with patients via E-mail, as most patients visited just simply needed re-assurance of their progress. Therefore communication via E-mail could save time for the clinic, for patients in emergency conditions.