Disasters, asylums, and plans: forensic psychiatry today.

Abstract

The first story concerned a man in his early 30s, who for many years had harboured paranoid, hypochondriacal ideas. He had had repeated admissions to his local mental hospital, without much effect, though he always maintained that in hospital he felt safe and relaxed. But when hospitals were no longer prepared to keep him he said that if we didn't get him into hospital soon he would to do something; won't commit suicide, he said, if I do, I will take someone with me. I agree with MacDonald,' who urges us to take such threats seriously, and I referred him urgently to another local mental hospital for possible admission. The consultant who saw him regarded his problems as more social than medical and once more not suitable for admission. At this news he set fire to the curtains in the out patients' department and ran off. Later he was found by the police after he had started a more serious fire in the nurses' home of the hospital concerned. It later transpired that he had previously started other fires-two in churches, and one in another outpatients' depart ment where admission had been refused. The second case was a man in his mid-50s. An impulsive, violent, and lonely man. Under stress he tended to become paranoid and to lash out in a brutal manner, and he had spent most of his life in prison. At the time I saw him he was charged, yet again, with a vicious assault on an old woman. To pay off an old score he decided to burgle a house but was alarmed to find, when he got there, that an old lady was at home. He threw her down the stairs and ran off. At his trial the judge was very reluctant, in view of the uselessness of the procedure, to send him back to prison. I was asked, therefore, to try and find him a bed in a hospital. This I failed to do but offered the court the option of his attending my outpatient clinic. To my surprise this was accepted with a special five-year binding over order. Though he was somewhat afraid of me and never entered treatment in any active sense he remained cheerful and contented for some time largely because he found a place in a good hostel. Unfortunately this had to be closed after some months and once more he was back on the street. He became tenser and tenser and pleaded for help with accommodation which I, a voluntary society, and two probation officers were unable to supply. One Saturday evening he attacked and robbed an old lady. This time the same judge that had bound him over sent him to prison for seven years. The third disaster concerned another single man, this time in his mid-40s, with a long prison record for violence which mainly occurred when he was drunk. He had attended my clinic for five years. Occa sionally I would have him admitted for a month or two to an alco holism inpatient unit but usually he would run off after a while and return to drinking. During one of his periods in hospital he met a disturbed but beautiful young woman patient. They became very friendly and he went to live with her in her mother's house. Inevitably, however, things went wrong and he terrorized the whole household. After a terrible scene, during which he was rejected byhis girlfriend, the police were called, he was brought to hospital, and admitted as being potentially homicidal and suicidal. After some weeks a social worker tried unsuccessfully to find him some hostel accommodation, and so he was discharged to his usual lonely bed-sitter. He soon found him self out of work and unable to pay the rent. His landlord gave him notice and one week later he took a massive overdose and killed himself. In each of these cases the crisis was precipitated by actual or impending homelessness. It would be naive to argue a direct causal link between ill-health and violence or between social stress and violence.2 Nevertheless, three propositions are worth considering. Firstly, these disasters need not have occurred; secondly, if, as a society, we are serious about reducing crie and protecting our citiiens then we will take steps to see that these social pressures do not bear down on people who are unable to carry them; and, thirdly, maybe the only really effective treatment which could have been made available to these men (and wasn't) was old-fashioned voluntary asylum. Based on a lecture given to the Northern Counties Psychiatric Association on 3 November 1973