Therapy - There's a Novelty

I find this opinion piece from the Guardian resonates with much of my own practice over the years and particularly the difficulty in accessing psychiatric and psychological provision for clients. As is becoming routine now, Probation doesn't get a mention and I've absolutely no confidence things will improve, not least due to our changed training, role and experience.   

Why we should be giving therapy to violent offenders

As a forensic psychiatrist I have learned that helping prisoners confront their offences is best for them, and for society.

Throughout my career, people have asked me why I do what I do. I’m a forensic psychiatrist and psychotherapist; I’ve spent three decades working with people in prisons and secure hospitals who have committed violent offences. I give therapy to those struggling to articulate unspeakable things and come to terms with their new identities as offenders.

This means listening without judgment to things that in any other circumstances would produce horror and revulsion. For example, a man’s account of how he killed four people and severed one of their heads to make disposal of the body more manageable, or a woman’s insistence that the victim she stabbed was possessed by a demon. A man who insists his ex-lover made him jealous relates how he strangled her; a young mother blames “useless” medical professionals for her baby’s multiple trips to the emergency room. Why should we help “those people”? Aren’t our resources better spent helping their victims or other law-abiding citizens who need treatment? Such questions reveal a great deal about the society we have created.

“Why wouldn’t we help?” is my usual reply. There is a nuance here that some people may not wish to acknowledge: in prison, the identities of victim and perpetrator are not always distinct. Most of our prison population qualifies as both; recent studies in the UK and the US confirm that most convicted offenders have an experience of trauma, abuse and violence at least four times higher than the general population.

The way a society treats the least of its members is a kind of barometer of justice. In the UK, as in many other countries, the punishment for criminal rule-breaking is deprivation of liberty. Once someone is incarcerated, we have committed to helping them change and become less risky. Aside from a small subset of extreme cases, it is reasonable to believe that most offenders can return to the community after serving their time and live productive, crime-free lives. This is a concept enshrined in UK law since the Penitentiary Act of 1779, which made the rehabilitation of prisoners a function of all prisons.

But that mission is not always accomplished. Our justice system and the programmes in prisons designed to reduce recidivism often fall short. Resourcing is insufficient; the most recent survey from the National Audit Office indicates that among prisoners in England and Wales, as many as 90% have poor mental health, including PTSD and depression. Perhaps only 10-20% of the most acute cases will ever get seen by a forensic professional like me. On release, ex-offenders contend with economic and social problems that can quickly drive them back inside. Within the female prison estate, for example, more than half of women face homelessness when released.

People grow out of violence on what is known as the “age-crime curve”: most violent offenders will desist over time, with rule-breaking and harmful behaviours dropping off rapidly after 35. Treating younger people effectively in prison makes it less likely that they will return in later life. And given the costs of keeping someone incarcerated (around £40,000 per year), providing therapy is time and money well spent – practical and compassionate in equal measure.

In my role as a forensic psychiatrist, I coordinate medical treatment within secure psychiatric hospitals, including Broadmoor, where I’ve spent much of my career. I also offer therapy, individually and in groups, to patients willing to look at how their minds work. The process can be halting and difficult. Many of my patients lack emotional vocabulary and struggle with trust.

But often there is progress, however subtle, and there is hope. I have known a jealous man who strangled his lover move from self-righteousness and suicidality to acceptance and a willingness to take responsibility for his actions. I have watched a woman go from being a victim of her mental illness to someone who reduced her risk by gaining a new understanding of her “demons”. Taking agency is the first step towards recovery, and I am constantly humbled when I see the changes that can follow.

Sometimes I work with legal colleagues to assess a person’s state of mind for the family or criminal courts. In cases before the family court, like the young woman who blamed doctors for her baby’s “mystery illness”, I will recommend treatment. But it is often unavailable for mothers who need it – another sad indicator of our society’s priorities. In criminal cases, the psychiatric evidence I provide doesn’t get people a more lenient outcome or a “cushy” transfer to secure psychiatric care. The notion that a secure hospital is better than prison reflects how little many of us know about the double stigma of being both an offender and mentally unwell.

I can attest that most prisoners recoil at the prospect of being “nutted off” (sent to psychiatric care from prison or directly upon conviction) because of the stigma this involves and because they have more autonomy in prison. Prison may be by turns boring and terrifying, but you’re generally left to think your thoughts alone. When I have run group therapy sessions for homicide perpetrators, prisoners have spoken about watching the TV show Big Brother and likened it to their lives in the secure hospital. Their time is highly structured, and people like me scrutinise their every move and thought. I wonder if that “cushy” notion derives from a general belief that anything must be better than prison. Or perhaps the word “therapy” is associated with coddling, like a massage at a spa, rather than a hard and painful look at parts of your mind that you’ve been avoiding your whole life.

Doctors go toward suffering without judgment. We do not deal in absolutes but attend to what we can discover through listening, observation, and testing. Although there will be people who can’t or won’t change their minds for the better, I’ve found that most violent offenders are interested in understanding how they got into this mess and how they can do better in future. We know so much more today about the miraculous capacities and plasticity of the mind, particularly the still-developing young mind. We also have a wealth of research evidence about what types of therapy can make a difference. Failure to use such knowledge would be a kind of madness on our part. We all want the world to be a safer place. I suggest the pressing question about the treatment of violent offenders is not “Why bother?” but “Can we afford not to?”

Dr Gwen Adshead is a forensic psychiatrist and psychotherapist, and co-author, with Eileen Horne, of The Devil You Know: Stories of Human Cruelty and Compassion (Faber)

Is It Ethical?

Was I the only one concerned at the sentence passed down the other day on Muhiddin Mire? This from the Guardian:- 

Leytonstone knife attacker sentenced to life

A mentally ill taxi driver who cut the throat of a stranger at a London tube station has been given a life sentence with a minimum term of eight and a half years after a judge concluded the attacker was motivated by Islamic extremism. Muhiddin Mire, 30, who has paranoid schizophrenia, told police the rampage in December 2015 was an act of revenge for coalition airstrikes in Syria, which the UK government had voted to support three days previously.

Judge Nicholas Hilliard, the recorder of London, told Mire he would be immediately transferred to Broadmoor, the high-security psychiatric hospital in Berkshire. The type of sentence handed down to Mire means that if he is found to be free of symptoms and subject to review he could be transferred to prison to serve the remainder of the term. Hilliard said: “This was an attempt to kill an innocent member of the public for ideological reasons by cutting his throat in plain sight for maximum impact.”

Mire, who had downloaded Islamic State propaganda before the attack, was convicted in June of attempted murder for stabbing 56-year-old Lyle Zimmerman and threatening four other travellers at Leytonstone station, east London.

But doctors giving evidence to the hearing conflicted over whether Mire’s mental illness was the sole reason for the attack. Dr Shaun Bhattacharjee, a Broadmoor forensic psychiatrist, told the court Mire’s interest in extremism was a symptom of his mental disorder. But Dr Philip Joseph told the judge it was possible for Mire’s obsession with Islamic terrorism to be separate from the illness.

Ultimately, Hilliard sided with Joseph’s argument. “What the defendant was intent upon was designed to intimidate a section of the public that were there to witness what he was doing. This was not carried out in secret but very brazenly indeed. It was carried out to advance a religious or ideological cause, namely Islamic extremism.” Hilliard said Mire’s interaction with commuters in the tube station during the attack was evidence of his awareness of what was going on around him.

It was revealed during an earlier hearing that Mire was sectioned in 2006 and released with a prescription for antipsychotic medication after two weeks in hospital. He was put in touch with a community mental health team upon his release but soon lost contact with them and stopped taking the medication. In the years before the attack, Mire became increasingly unwell and was probably already exhibiting symptoms of paranoid schizophrenia.

Among “strange” ideas Mire had was a belief that the former prime minister Tony Blair was his guardian angel and that he had been possessed by evil spirits, the court heard. His paranoid delusions later manifested in a belief that he was under surveillance by the security services and was being followed.

Bhattacharjee told the court the prevailing culture – in this case a heightened state of tension over Islamic terrorism – could often inform schizophrenics’ delusions. As an example, Bhattacharjee said in the 1970s some paranoid schizophrenics experienced delusions related to the IRA and Irish terrorism.

During the attack, Mire shouted, “This is for my Syrian brothers. I’m going to spill your blood.” But Joseph told the same hearing that this interest in extremism was separate from his mental illness, not fuelled by it.

Mire told police in the hours after his arrest that the attack was an act of vengeance for coalition airstrikes in Syria. On 2 December, the government voted in favour of extending bombings against Isis targets in the Middle East to include Syria. He had images of the soldier Lee Rigby and a British Isis killer on his phone, along with material linked to the terror group. The court heard Mire started viewing Isis videos online three years before the attack.

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There are a number of things I simply don't understand about this case, not least how someone mentally ill can be held criminally responsible for their actions? In addition, I've always been concerned about conflicting expert medical evidence when commissioned by either the prosecution or defence. Why can't the experts be commissioned by the court instead and avoid the suspicion that an experts opinion is being cherry-picked? Finally, I didn't understand the mechanism for sending him to Broadmoor Special Hospital straight after sentence, until I read this from the Mental Health Cop blog:-

Muhiddin MIRE was today sentenced by a criminal court following the attack at Leytonstone Underground station last December that made prominent national headlines. I admit, I had a bit of a job initially piecing together what exactly the court had done, following vague media reports that appeared somewhat to contradict themselves! One simply claimed the man had been sentenced to ‘life in jail’ whilst another that he would ‘begin his sentence at Broadmoor’. This made me wonder whether, in fact, the court had sentenced him to what’s known as a hybrid order – this turns out to be exactly what they’d done; so I thought I’d quickly explain it, in case of any doubt as to what this means!

Before I do, I’d observe that somewhere between being charged with attempted murder by the police and his sentencing today, he has been transferred between the criminal justice and mental health systems. When he first appeared at court, there would be no power for Magistrates to remand the defendant to hospital under the Mental Health Act. At or after his first appearance at the Crown Court, he could be transferred and that has obviously occured and facilitated a period of assessment by the psychiatrists who have given professional opinion to the sentencing judge. The defendant has pleaded guilty to the offence, notwithstanding that his mental illness is serious enough to mean he reaches the threshold for admission to hospital under the MHA.

So this is yet another example to prove the point that serious mental illness does not always equate to a lack of criminal responsibility for serious crimes. Indeed, as previously pointed out, attempted murder is the most difficult kind of assault to prove – because a charge of murder succeeds if it can be proved that the defendant intended to kill or seriously injure the victim; attempted murder requires proof of intent to kill. A notably higher threshold to satisfy.

HYBRID ORDERS

A hybrid order means that the court can issue a ‘normal’ criminal sentence of imprisonment to any defendant over the age of twenty-one, but they will first be admitted to hospital under the Mental Health Act for treatment. It then depends how long the patient’s treatment lasts as to whether they are discharged from hospital or transferred to prison to complete that original sentence. All of this is done under s45A of the Mental Health Act 1983.

So in Muhiddin MIRE’s case, he was sentenced to ‘life imprisonment with a recommendation that he serve a minimum of 8.5yrs in jail’, commencing with the treatment aspect of the hybrid order. Let’s imagine he remains in hospital for 6yrs receiving treatment, he will then be transferred to prison for a minimum period of 2.5yrs before the Parole Board would be able to take any decision about his release from prison. Were his hospital treatment to last 9yrs, then release would beconsidered – but not necessarily granted! – as soon as the clinician in charge of his care recommended discharge from hospital. If the Parole Board did not grant immediate discharge, he would be transferred to prison to serve further time in jail until his case for release is reconsidered.

Finally, anyone made subject to a hybrid order after conviction for any offence specified in Schedule 1 of the Criminal Justice Act 2003, will be subject to the provisions of Multi-Agency Public Protection Arrangements, or MAPPA. These are arrangements which aim to ensure, amongst other things, post-release mechanisms through which public authorities cooperate to share information, to ensure risks are properly managed in the community, if or when a patient is discharged or prisoner released.

So this is the only form of sentence which combines two periods of detention: first in hospital and then in prison. These orders seem to becoming more popular amongst judges, the point being that they prevent people with serious mental illnesses who are convicted by the courts of being subject to a far shorter period of detention under a (restricted) hospital order than they would have done if they had been sentenced only to a period in prison.

And we could debate the ethics that sit behind that approach, all day long … on another day!

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Somewhat strangely, I notice that the regular legal bloggers have yet to comment on this case.

Juries

The subject of juries has come in for quite a bit of discussion recently as a result of the first Vicky Pryce trial and the now infamous ten questions they put to the judge. They were eventually discharged and a fresh trial ordered when unable to agree a majority verdict and raised questions as to their ability of being able to 'grasp the basics' concerning the issues involved. 

Of course we can never know what went on in the jury room as such deliberations must remain sacrosanct, but the measured view seems to be that the questions arose not from ignorance, but rather from some members exasperation and a valiant effort at trying to seek confirmation of the issues and therefore a decision. Obviously this was not to be and a re-trial is in progress.

I want to highlight a case where a jury has made a decision, but a deeply disturbing one in my view. As always, any discussion of a case without full knowledge can be risky, but the case of Nicola Edgington is truely shocking and one I simply do not understand. 

Most press attention has focused on the IPCC report confirming that police failed to deal correctly with this woman's numerous telephone pleas for help. As someone who had already been subject to a Hospital Order for killing her mother some years before, she was becoming desperate to be 'sectioned' because of her state of mind. In one call she reportedly said 'the last time I felt like this I killed my mother' and yet she was not assessed or detained. 

Tragically for everyone concerned, because this woman was not dealt with properly, she armed herself with a knife and committed two horrific attacks on random members of the public, almost decapitating one.

I think most people hearing the broad details of such a case would not require expert psychiatric opinion to confidently come to the conclusion that at the material time the balance of her mind was significantly affected by a severe mental illness and therefore how could she be found guilty of murder?

To most people, acceptance of a guilty plea to manslaughter on the grounds of diminished responsibility and a Hospital Restriction Order would seem much more appropriate. But instead, astonishingly in my view, a jury convicted her of murder and the judge in summing up is reported as saying 'she should take full responsibility for her actions' and gave her a tariff of 37 years. 

The saddest and most worrying aspect of this case in my view is that in all probability she will at some point be transferred from prison to Special Hospital due to her psychiatric state. She needed treatment all along and if she had been dealt with correctly, a life would have been spared and another wouldn't now 'be doing life.'
        

Endgame

I notice that Ian Brady features in the news again, this time as a result of a solicitor publishing the transcripts of two meetings held with the convicted murderer at Ashmore Special Hospital in 2006. Representing Winnie Johnson, mother of missing victim Keith Bennett, the solicitor apparently met with Brady at his request and attempted to persuade him to reveal the whereabouts of Keith's body.

This surprising news comes hard on the heels of the recent Channel 4 documentary 'Ian Brady : Endgames of a Psychopath' screened just days before Mrs Johnson's death last week. I assume that as a result of her death the solicitor feels able to breach confidentiality, hopefully in consultation with her family, but I'm still a little surprised by the timing, being just three days before the funeral. 

But then surprising can only be my reaction to the Channel 4 film and the part played by so-called Mental Health Advocate Jackie Powell. You will recall that transmission was presaged by widespread media coverage of her arrest and charging with an offence of Preventing the Lawful Burial of a Body. This came about as a result of her revealing that Brady had handed her a sealed envelope with instructions that it only be opened following his death. She speculated to the producer of the film that the envelope may contain details of Keith's whereabouts. No wonder all hell broke loose when Greater Manchester Police found out and eventually decided to act, obtaining Search Warrants for both Jackie's home and the hospital.

To be honest there was nothing particularly surprising in this film about Ian Brady and his continued highly psychopathic and manipulative traits, but what exactly is going on with long-term visitor Jackie Powell? How on earth did she feel it appropriate to be cooperating with a film crew if she was a Mental Health Advocate? Has she no line manager or support network reigning her in a bit when dealing with one of the most manipulative patients it's possible to imagine? I gasped out loud when I'm sure I heard her say that she is Executor to Brady's Will and has an Enduring Power of Attorney over his affairs. Surely this cannot be right or sensible for a Mental Health Advocate?

Well, rooting around on the internet as one does, I came across this statement by Action for Advocacy expressing very similar concerns. According to this the whole concept of legally-appointed Mental Health Advocates for certain patients detained compulsorily only came about as a result of the Mental Health Act 2007 and enacted from 1st April 2009. Such persons have to be qualified and appropriately supervised.  It will be interesting to see what comes out about Jackie Powell's role in this whole sorry saga. 

Meanwhile, Brady's Mental Health Tribunal Appeal into his demands to be declared sane and thus be returned to prison remains adjourned following his recent seizure. Having been forcibly fed since 1999, he hopes to regain ultimate control over his destiny by being allowed to starve himself to death in prison. This will only be possible though if the medical profession conclude that he is no longer mentally ill and are able to convince the Tribunal. 

For those who are pondering if he has a probation officer, I think that will indeed be the case as he remains a convicted murderer subject to Special Hospital transfer and restriction under the Mental Health Act 1983.          

Some Observations 4

I've been meaning to say something about the Channel 4 series 'Secret Millionaire' for some time and the most recent episode set inside HMYOI Brinsford seems as good an excuse as any. Sadly though I thought it was one of the most uninspiring to date, even though it was highlighting the appalling levels of illiteracy amongst inmates. Nevertheless the work of the Shannon Trust is extremely important and I notice that it's Founder only died recently.

I admire the concept of introducing very wealthy people to extreme examples of how the 'other half' live and over recent years the programme has provided some really uplifting viewing in terms of highlighting work done by some inspirational volunteers all over the country. It must be coming to the end of its 'shelf life' though as there can't be that many people who are not aware of the programme and would rumble things as soon as camera's appear. I guess that's why the producers are trying some different angles, especially in placing participants in situations even further outside their comfort zone than normal. I notice that the Guardian was particularly scathing about the episode set in Middlesbrough involving deaths from epilepsy and the degree of 'manipulation'. Of course it has to be 'set up' but on balance, I think it's worth doing and succeeds in not being at all cheesy. 

The BBC Radio 4 'Today' programme has recently run two reports from inside Broadmoor Special Hospital in an attempt to show that such places are not that scary and that real therapeutic work goes on in helping patients recover. Broadmoor and Rampton are very unusual places indeed. They still both look like Victorian Gaols that were placed deliberately in isolated locations and as a consequence have struggled to overcome the problems stemming from a workforce that mostly live in the small local community, many of whom are inter-related and often second or third generation.

They may be hospitals, but the majority of staff are prison officers that just happen to be in 'mufti'. The other Special Hospital, Ashmore in Liverpool, has always had a different feel. I have never had any doubt that excellent work goes on at all three establishments, but believe me they can be scary places. Many patients will have a personality disorder in addition to a mental illness and I'm still not sure the former can be 'treated'. As with prison, some residents kill. Others are routinely violent. Many self-harm. Some will never come out, despite us being told the average stay is six years. Release from Special Hospital does not necessarily mean a return to the community. It could well be a return to prison or quite often a Regional Secure Unit. 

In closing I'll mention Louise Casey who was on BBC Radio 4 recently in her latest incarnation as Victim Commisioner. I have no doubt that there is a valuable piece of work to be done here in relation to advocating on behalf of victims and ensuring adequate resources are provided. However, I feel I have to make the point that in my experience many offenders have been victims themselves. The sad fact is that in reality victims and offenders can often be one and the same. It's this sort of revelation that only becomes apparent through so-called restorative justice when victim and offender meet each other as part of a voluntary and carefully managed process. But more of that another day.