Violence? What Violence?

Dr Dermot J Ward

Remember it was the Victorians, of course less sophisticated  we believe than us modern mortals, who began a humane process of caring by their best lights, for the severely mentally ill and disordered. The building of mental asylums recognised that the wider society also needed protection.

That there was altruism in this development is denied only by a churl. By todays' standards the  public expenditure was vast. The Victorian philanthropists truly put their money where their collective mouth was. Recognition of the need for compulsory detention and treatment continues to this day as a justified piece of statute, albeit carefully husbanded by modern mental health acts. Psychiatric illness, no matter how hard some people may wish it, cannot be airbrushed out of reality. 

There is no comparable large chunk of legislation for physical illness (that surrounding certain infectious diseases need hardly be mentioned). So, mental illness is different. It will, I suggest, continue to be regarded as different from say emphysema or hypertension. It is fatuous to pretend otherwise. Worse, it harms valiant and necessary efforts to reduce the additional hurt to patients when, because inpatient facilities can be so scant, that urgent informal admission, which might avoid the experience of compulsory hospitalisation and its added stigmatising, is too often postponed until even graver psychological and behavioural deterioration forces that admission. Such delay is damaging to both that patient's prompt medical treatment and as the patient waits in the community, further fodder is provided for stigma and more prolonged illness.     

In recent times it has become fashionable within the mental health lobby to claim that there is no more likelihood of violence from a mentally disordered population than from a general one. To anyone of medical experience in the field this is poppycock. No responsible person would wish to inflate the risk factor. But it is both dangerous and irresponsible to pretend it does not exist and especially so to use such distortion to justify further NHS reduction in hospital bed numbers.

Obliquely the issue of violence was highlighted by BMA NEWS (1) BMA Central Consultants and Specialists Committee chairman, Peter Hawker, wrote to the Information Committee expressing concern that widespread public availability of personal data, particularly home addresses, via websites such as192.com, posed a risk to the safety of doctors, "especially psychiatrists who deal with unpredictable and potentially violent patients".  So there, it's official! Added dangerousness does exist in the psychiatric population after all. Not that those reasonably informed, and without a political, agenda ever thought otherwise.

A DoH report (2) has shown that in 2001 there were 50 000 detentions under the MHA ie 20 000 more than10 yrs ago. That is a huge increase over one decade and difficult to explain by other than swingeing inpatient bed scarcity leading to more and more delayed inpatient treatment until illness deteriorates to crisis level invoking greater use of compulsory detention. Also a snapshot on 31Mar2001 showed 13 900 detentions under the MHA compared with 12 900 the previous year , a rise of 8%.

Dr Tilman Steinert (3) head of a German research department and clinical department of general psychiatry addressed a paper in the same BMJ issue by Walsh et al Reducing violence in severe mental illness: randomised control trial of intensive case management (ICM) compared with standard care (SC) in the community (4) . Result: despite essentially doubling the community team numbers there was no signficant reduction over a 2 yr period with IM case manager caseload 10-15 whereas SC caseload was 30-35. Dr Steinert  commented drily, "Actually, a rather effective treatment for violence in seriously mentally ill people is available, but only for limited periods: hospital treatment.  Our group has shown a continuous day by day reduction in the incidence of violent behaviour among inpatients with schizophrenia, resulting in very low rates after some weeks of treatment."

1.BMA NEWS Feb 2, 2002 p2 "Doctors' details to get better protection' by Lisa Pritchard.

2.BMJ News, BMJ323 p114 2001[Nov 17]

3.Steinert T Reducing violence in severe mental illness.[editorial]BMJ2001;323:1080-1

4.Walsh et al Reducing violence in severe mental illness: randomised control trial of intensive case management compared with standard care.BMJ2001;323:1093--6.