June 25, 2013

expert reaction to Ian Brady mental health tribunal

Moors Murderer Ian Brady spoke publicly for the first time in 47 years as he appeared before a mental health tribunal at Ashworth Hospital.

Prof Nigel Eastman, Emeritus Professor of Law and Ethics in Psychiatry and Honorary Consultant Forensic Psychiatrist, St George’s University of London, said:

“Reports of Ian Brady’s tribunal and of his testimony are unearthing a number of key issues and common misconceptions regarding forensic psychiatry.

“Forensic psychiatry is a branch of medicine, as is all psychiatry. However, clinically it deals with individuals with mental disorder who exhibit serious offending and thereby operates at the interface with law and legal process. As a result it is properly open to forms and degrees of scrutiny which do not apply commonly in the rest of medicine.

“The clinical discipline is pursued both within secure psychiatric hospitals, plus within community services, and also prison healthcare.

“People are not lightly assigned to psychiatric hospitals; and decisions are made by teams of highly trained experts from a range of disciplines utilising extremely detailed methods of clinical assessment and tests in order to determine their decisions or recommendations. Within such assessment, use is made of a great deal of evidence available concerning the efficacy, or not, or particular treatment and care interventions, as well as about risk assessment and management. Ultimately, however, such decisions are always subject to legal scrutiny, as is currently occurring in relation to Brady.

“Treatment depends upon the nature of the disorder, including mental illness, for example schizophrenia, and developmental personality disorder. It can include drugs and psychological therapies. The best evidence of treatment effectiveness exists in relation to mental illnesses, often with evidence of high success rates.

“Whilst paranoid schizophrenia attracts much public attention in relation to violence (although it is always worth noting that people with schizophrenia are far more likely to harm themselves than perpetrate violence on others) any form of mental disorder can trigger detention under the Mental Health Act. And there are significant numbers of people with personality disorder who are currently detained in psychiatric hospitals in the UK.

“The present hearing relating to Brady raises the question ‘how is a patient determined to be suitable for release from a psychiatric hospital, either into the community or, if they are subject also to a prison sentence, via transfer to a prison?’ Whilst there are patients who remain in care in a psychiatric hospital for very long periods, the majority improve sufficiently to leave. This can occur by way of a clinical decision alone. However, in relation to mentally disordered offenders who have committed serious offences, such decisions are made by Mental Health Tribunals, set up by statute and legally chaired, usually by a judge, advised by clinicians.

“It is understandably questioned on occasions whether someone subject to detention in hospital might be feigning mental disorder, or recovery. However, it is very difficult to fake either state, particularly where the individual is subject to twenty-four hour observation in hospital, extending often over many months or years.

“The questions that forensic psychiatry address are necessarily contentious, and are therefore often subject to legal scrutiny. However, the role of clinicians remains to advise on clinical matters, whilst legal process ultimately determines decisions such as discharge, or continued detention.”

Prof Peter Kinderman, Professor of Clinical Psychology and Head of the Institute of Psychology, University of Liverpool, said:

“Many of us disagree very profoundly with the concept of mental illness itself. And, even if you accept that the concept is in any sense valid, the evidence is that we can’t agree – we don’t know – when somebody is ‘mentally ill’. The definitions shift and change, are disputed (c.f. DSM-5) and the statistics demonstrate clearly that ‘experts’ can’t agree.

“There are no ‘tests’ – there’s clinical opinion, based on disputed concepts. We can’t – and don’t – agree, and so the sense of robustness is pretty much absent. Yes, we care for people in difficult circumstances, and our formulations of peoples’ problems are probably quite consensual, but there are no robust ‘tests’.

“It is it very likely that someone will get better from something like paranoid schizophrenia… if you can avoid psychiatry (most people have positive outcomes), but quite unlikely if you take psychiatric medication long-term. Several experts (Whittaker and Moncriff, principally) are very sceptical of drugs per se; even for so-called ‘depression’ and ‘schizophrenia’. Ian Brady has been diagnosed with ‘personality disorder’ the most invalid and unreliable of diagnoses, and drugs are not even recommended in such cases. 

“We don’t really know what not being ‘better’ is, so we can’t define ‘better’. ’Better’ also doesn’t in any sense relate to ‘no longer a danger to others’ (since these are different concepts). And, of course, people who are ‘better’ can always develop problems later.”