Risk assessment is not clear cut

Combating cases of combined filicide-homicide-suicide is about balancing rights and Una Butler has done us a service by opening the debate, writes Des Kavanagh

TO the general public, violence against self or others may be perceived as synonymous with mental ill- health. The reality is very different. The vast majority of people suffering mental ill-health present no danger to anyone.

Indeed, when one considers that 0.8% of the population suffers from some type of schizophrenia and that mental health issues are deemed to be the third most common reason for persons attending their GP, it becomes clear that the prevalence of mental ill-health in the population is very high and violence among that part of our population is miniscule.

On the other hand, some of the episodes of violence committed by those suffering with a mental illness are extreme in nature and attract significant public attention. In recent weeks, it has come to public attention that about 52 people have been killed over the last 12 years in combined events of filicide, homicide, and suicide.

The idea of a person killing his children, partner, and himself is repugnant to everything we hold dear. We cannot imagine what drives a person to kill his/her children. It runs against our normal human predisposition of wanting to love and protect our children.

Nevertheless, it happens, it shocks us and seems to point to a shocking level of violence amongst those who are deemed mentally ill. It is also the case, however, that not all of those who kill their children suffer from a mental illness.

While the majority of those who kill their children are male, it is not exclusively so.

It has now been suggested that the next Mental Health Act should include provision for mandatory risk assessment and the obligating of clinicians to insist on the inclusion of family in the decision-making in the treatment of mentally-ill persons.

The mentally-ill person who murders their child may be psychotic or they may be very depressed and see the world as an awful place from which they want to escape and want to bring their family with them, to save them from the awful and depressing reality of life, as they see it.

In some cases, staff and/or family members pick up an indicative threat by individuals against self or family. In these cases, it is of course essential that a risk assessment is carried out. This would be normal practice for the mental health team.

However, in many cases there is no discernible threat until the catastrophic event actually happens. To put in place a mandatory risk assessment would be extremely challenging for all concerned :

* To whom would this apply?

* How would it be proposed to compel a mentally-ill person to comply with a mandatory risk assessment?

* Would mandatory risk assessment not be seen as highly intrusive and breaching the civil rights of those suffering from mental illness?

The mental health services are highly dependent on families to support their loved ones when suffering a mental illness. In the absence of sufficient mental health professionals to populate community mental health teams, many families have, not unreasonably, dubbed “community care” family care.

Families regularly report that:

* Their loved one is overly optimistic about their ability to cope with the impact of their illness;

* The patient understates the effect of their symptoms on their lives;

* The patient may be completely misleading their clinicians;

* The nature of some mental illnesses often results in patients regarding the most extreme and bizarre behaviours as completely reasonable.

At the same time, the patient- clinician relationship is sacrosanct.

In some cases, patients absolutely insist on the exclusion of family from their care. They may instruct the doctor not to talk about them to their family members. They may blame family members for their illness. What is the clinician to do?

However, it should be noted that the majority of patients are delighted to have the support of family and will include them in the care process. The community mental health nurse will often provide the treating clinician with reports from family members which help to inform decision-making.

As president of the European Representative Organisation for Psychiatric Nurses, I know the huge work that family groups like EUFAMI carry out on behalf of the mentally ill: From raising awareness to campaigning for better services.

I have listened to the frustration of family representatives across Europe when faced with lack of inclusivity in the care of their loved ones. But how can universal family involvement be achieved? With the permission of the patient, that’s no problem, but when the patient rejects family involvement, what is to be done?

Today, it is asserted that mental illness is just another illness, that it should be demystified and treated in the same way as physical ill-health. We have moved away from the paternalistic approach, where we decided what was best for the patient, to what is described as the libertarian approach, where care is provided in the least restrictive way possible and in which the patient’s right to self determination of care and co-operation with care is respected, except for a small number who, because of their illness, are detained against their will.

The current approach carries risks and when it goes wrong it is easy to revert in our thinking and seek the comfort of the paternalistic approach. The old ways were not appropriate and in many ways were abusive of patients’ human rights. I am not sure we have it right yet. Surely a balance needs to be struck between the rights of the person, the rights of the family and the rights of society?

Una Butler has done us a great service in opening this debate. She has suffered terribly because of her husband’s depression. She warns that her experience may be repeated for others. She seeks to protect others from her appalling experience. But is that possible without compromising the rights of the mentally ill?

* Des Kavanagh is general secretary of the Psychiatric Nurses’ Association

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