Prison or hospital?
MEDICINE JOHN ROWAN WILSON
A woman with a history of unstable behaviour was found guilty of attacking her neighbour with an iron bar. Psychiatric examination showed her to be suffering from a serious mental disorder and, under the provisions of the Mental Health Act of 1959, she was com- mitted to a mental hospital for treatment. Four months later she was discharged as cured. Within a year she killed a man with an axe, was found unfit to plead and removed to Broadmoor.
This story was told by the Lord Chief Justice to illustrate the dangers involved in the 1959 Mental Health Act if it is not cautiously applied. The Act contains provisions for indi- viduals with diminished responsibility by reason of mental disorder, and makes it possible to send them to mental hospitals rather than to prison. Here, instead of being punished, which is quite irrelevant and possibly harmful in people of this kind, they can receive necessary treatment and be, with luck, restored to health and become useful members of society.
An excellent and progressive idea; but un- fortunately there are snags. The most obvious one is when there is simply no known treatment for the patient's condition. This tends to be the case with aggressive psychopaths, who form perhaps the most important group of dan- gerously deranged individuals. In a recent case involving a typical and very dangerous aggres- sive psychopath, Dr Lindesay Neustatter, one of our leading forensic psychiatrists, stated that while the man's responsibility was certainly diminished, he would not be susceptible to treatment and should not therefore be dealt with under the Act. He was accordingly sent to prison. While it is understood that this was intended not so much as a punishment as a measure for the protection of society, it nevertheless carries obvious undesirable features. What about the other prisoners? Or the prison officers? Aggressive psychopaths are a notorious source of violent and mutinous behaviour in jails. Surely they need special management in a place completely separate from ordinary criminals?
A different problem arises with depressives and schizophrenics. These patients may very well respond to treatment, and are consequently suitable for admission to hospital under the Act. But there is an appalling difficulty in de- ciding when they should be discharged from hospital. The patient may seem perfectly re- covered for quite a considerable time and then relapse, with disastrous results, soon after being returned to the outside world. This has hap- pened in a number of cases, of which the Lord Chief Justice quoted a particularly tragic example.
The psychiatrist finds himself in an agonising dilemma. If he plays safe and keeps the patient in hospital for a long period, he may be con- demning a normal person to prolonged incar- ceration in a psychiatric hospital—while if he gambles on the patient's recovery he may every now and then be setting the stage for another act of violence. His duty towards his patient on the one side conflicts with his obligations to society on the other.
There is another section to the Act, which the Lord Chief Justice has recommended should be used more often. This is known as a restric- tion order, which gives authority for the patient to be detained indefinitely at the will of the Secretary of State. The Secretary of State may, acting on advice, either terminate the order or make it into a conditional discharge. This effectively takes the question of discharge out of the hands of the psychiatrist treaties the patient and has aroused opposition on the part of some psychiatrists, who are reluctant to accept restraints on the right to declare when a patient is fit to rejoin the community.
But even this is not the end to the problem. A restriction order assumes that the psychiatrist is in a position to keep the patient incarcerated in the mental hospital. But in modern circum- stances, this is becoming increasingly difficult Modern psychiatric treatment hinges very much round the so-called 'open-door' principle. It has been shown that, for the vast majority • of psychiatric patients, bolts and bars are un- necessary and harmful. This is undoubtedly a tremendous advance in the management of the mentally ill. But it does mean that it is very difficult to prevent dangerous patients from escaping.
What, then, is the answer to these diffi- culties? Certainly it is not to turn the clock back and restore the old restrictive system. A mental hospital is, or should be, a community run on civilised lines. Similarly a modem prison is thought of as a centre where some kind of civilised rehabilitation of the criminal can take place. Both these important concep- tions are now menaced by a small group of dangerous patients who require special methods of control and supervision. These can only be applied in a particular kind of hospital, of which Broadmoor is an example. The problem can be solved only by building more mental hospitals like Broadmoor, where patients with a record of violence can be effectively separated both from common criminals and from the ordinary run of mental patients. Such hospitals are extremely expensive to build and to run, but this is an expense we shall have to accept- There is no valid alternative., . ti
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