Why the Mental Health Bill is pure madness

In a major book to be published next week Jeremy Laurance, health editor of 'The 'Independent on Sunday', argues that in the 10 years since the random killing of Jonathan Zito by paranoid schizophrenic Christopher Clunis, a desire to protect the public has taken priority over care of patients. Unless ministers strike the right balance between care and control, he warns, there will be more tragedies

A watershed case

The knife came from behind, swung with such great force that it penetrated the orbit of the right eye and entered the brain. The victim was caught by surprise, unaware of the presence of his assailant, a complete stranger, behind him. He had been picked, apparently at random, from among the crowd of people standing on a Tube station platform. His assailant turned out to be a mental patient who had been shunted back and forth in the mental health system and had seen more than 43 psychiatrists in five years.

The killing of Jonathan Zito by Christopher Clunis, a man diagnosed with paranoid schizophrenia, on 2 December 1992 marked a watershed in the history of mental health care in Britain. Up to that point the focus had been on the welfare of patients discharged into the community as the huge Victorian mental asylums closed. Many were living impoverished lives in dingy bedsits, forgotten and ignored. Stories exposing their plight had shamed politicians and the public and fuelled doubts about the hospital closures.

After the Zito killing, the nature of the debate changed. The focus shifted from the care of patients to the protection of the public. The psychopathic murderer became the new monster in our midst. Risk avoidance and public safety became the new watchwords.

The switch of emphasis had an enormous impact on the care of people with mental health problems. Concern about the welfare of the many was replaced by fear of the risk posed by the few. There are an estimated 600,000 people in England with severe enduring mental illness, most of whom have a diagnosis of schizophrenia or manic depression, but fewer than 1 per cent of them (4,000 people in England) are judged to need intensive care because they pose a risk to themselves or to others. Most are at risk of suicide, not homicide, and it is important to recognise what a small proportion – about one in 10,000 – of the population they are.

Nevertheless, the rare cases of homicide involving mentally ill people have dominated the debate about community care, and it is easy to see why. It was not the killing of Mr Zito that was shocking, tragic as it was, for we are used to violent death. What was shocking was its randomness. It was a pointless, motiveless crime and it tapped our deepest fears about people with severe mental illness – the "nutters on the loose" of popular prejudice.

A cost no society should tolerate

At Clunis's trial on 28 June 1993 at the Old Bailey, the judge, Mr Justice Blofeld, accepted his plea of not guilty to murder but guilty to manslaughter and ordered that he be detained in Rampton high-security hospital.

Six months later, the Ritchie inquiry into the killing delivered a savage indictment of the care Christopher Clunis had received and said the blame should be shared collectively by all the agencies involved. For more than five years he had been shunted between hospital, hostel and prison as his condition deteriorated and his violence increased, but no plans had been made for his care and there was inadequate supervision by doctors, social workers and police. "It was one failure or missed opportunity on top of another," the report said.

Although the Ritchie inquiry endorsed the community care policy, which it said worked well for the vast majority of mentally ill people, in a crucial passage it warned that there was a serious risk that repeated violent attacks by mental patients would discredit the policy and "exceptional means" were required to prevent them. "The serious harm that may be inflicted by severely mentally ill people to themselves or others is a cost of care in the community which no society should tolerate," it said.

That sentence, with its unequivocal warning, has been ringing in the ears of policy makers and practitioners ever since. It was the signal for a new, coercive approach to the care of people with mental health problems. Subsequent inquiries into killings by mentally ill people followed the Ritchie report's lead, calling for tighter controls on patients to the disquiet of psychiatrists who protested they were being turned into jailers. Supervised discharge, registers of dangerous patients, increasing detention, and a psychiatric service driven by fear of further killings were the result.

Avoiding risk

Three key factors have sustained this risk-avoidance agenda. The first was the pressure from carers' organisations which used the rare cases of homicide to keep the plight of mentally ill people in the public eye. The second was the Government's decision to order an independent inquiry into each homicide involving a mentally ill person, creating a blame culture in which avoidance of risk became the priority. And the third was the role of the press which played on the association between irrationality and aggression, but ignored other causes of danger, such as drunkenness, and took no account of the needs or civil liberties of those whom it wished to see contained.

The 1996 attack on Lisa Potts, a nursery teacher, in which seven children were severely injured by a deranged man, Horrett Campbell, wielding a machete, lifted concern to fever pitch. This was followed the same year by the gruesome killing of Lin and Megan Russell by Michael Stone, diagnosed with severe personality disorder.

The Michael Stone case proved to be the final straw for the Government. The disturbing allegation that Stone had been discharged from care because psychiatrists considered he was not treatable provoked outrage. Ministers declared that public safety must be paramount. The community care policy came under fire for allegedly dumping "dangerous lunatics" on to the streets without support. In 1998, the tide of criticism reached a peak when Frank Dobson, then Secretary of State for Health, declared: "Community care has failed."

Yet figures show there has been no increase in killings by people with a mental illness in the 40 years during which mental hospitals have been emptying. The argument that the community care policy has increased risks to the public cannot be sustained. Fewer than one in 10 murders are committed by someone with a mental disorder and they have accounted for a diminishing proportion of homicides as the overall murder rate has risen. Moreover, community care is popular, preferred by the users of the services and their carers. The asylums that became bywords for neglect have largely closed; community teams are now supporting people in their own homes; health and social services are working more closely together and users are increasingly involved in their own care.

A system driven by fear

The public and political focus on the tiny numbers who pose a risk has created a treatment culture that places public safety above individual care. In researching my book I toured the country visiting hospitals, sitting in on consultations, going out with crisis teams, visiting people's homes and talking to patients, professionals and carers. What I found was a service driven by fear in which the priority is risk reduction through containment – by physical or chemical means. In every contact with a person with mental health problems the question uppermost in the professionals' minds is: "Will this person kill themselves or someone else?"

It was not always like this. Professionals say that it is only in the past five years that the pressure from a government and public bent on pinning blame when things go wrong has produced a culture of containment, seen in rising detention, increasing use of medication, locked wards and growing dissatisfaction among the users of the services.

As the numbers detained in hospital have soared by 50 per cent in a decade, the protests have grown louder. The rise of the users' movement is the single most striking development. A plethora of groups representing different user interests has sprung up; magazines such as Openmind, Asylum and Breakthrough are flourishing; there is increasing professional support. People with mental health problems, who are mostly only intermittently ill and at other times fully capable of running their own lives, are demanding a greater say in their treatment.

A coercive law

The Government's response has been confused. On the one hand, it has embarked on what the Mental Health Act Commission has described as the quickest and most dynamic transformation of policy in the history of state intervention in mental illness. Mental health has been designated one of the top health priorities, along with cancer and heart disease; there is a new National Service Framework, a mental health tsar and a new drive to roll out intensive community care services nationwide backed by £300m of new investment.

But at the same time the Government revealed its authoritarian instincts in seeking to capitalise on the alarm caused by random attacks such as the killing of the TV presenter Jill Dando and the assault on George Harrison with proposals for a new, heavy-handed law to deliver a safer service, billed as the biggest change to mental health legislation for 40 years.

Mad or bad?

The most contentious element in the Mental Health Bill, published last June, is the proposal to detain dangerous mentally disordered people even though they have committed no crime. The Michael Stone case highlighted a fundamental dilemma about mental illness. Are people like him mad or bad? If mad they deserve treatment but if they are bad, who should be responsible for them? Psychiatrists resist being cast as jailers.

Personality disorder is defined as "an enduring pattern of cognition, affectivity, interpersonal behaviour, and impulse control which is culturally deviant, pervasive and inflexible and leads to distress or social impairment". Put another way, this means someone who is odd, not "normal" – not like their psychiatrist, that is – and in distress as a result. Personality disorder is not a mental illness. It is thought to be the result of poor parenting, or neglect or abuse in childhood. One in 10 of the population is estimated to have some degree of personality disorder, but only a tiny proportion is judged anti-social or psychopathic. These few damaged individuals have often had awful life experiences and learnt the only way to cope is to lose all emotion – they don't trust anyone and they become cruel and dangerous.

John Mahoney, joint head of mental health policy at the Department of Health, summed up the dilemma that they pose for policy makers. "Some people with dangerous severe personality disorder are very bright yet they are also sadists and child killers. The public can't accept someone like that is sane. They insist they must be crazy to do something like kill a child."

Professor John Cox, president of the Royal College of Psychiatrists, said: "It is not our job to cure society's ills. Our job is to treat people and get them better. The idea that it is our job to modify unwanted behaviour brings psychiatrists too close to being agents of the state whose job is to modify behaviour the state doesn't like." This view was echoed by Margaret Clayton, chair of the Mental Health Act Commission. "The white paper goes close to laying the foundation for social engineering – 'We don't approve of this behaviour, so we lock you up.'"

The Mental Health Act Commission was fiercely critical of the plans. But government lawyers say detaining people who have committed no offence could avoid falling foul of the Human Rights Act if it is restricted to those who have already committed a serious offence.

However, a crucial flaw in the Government's position was highlighted by Professor George Szmukler, dean of the Institute of Psychiatry. If "high risk" patients are to be detained for the protection of the public rather than in their own best interests, then the key factor determining who is detained should be dangerousness rather than mental illness. But on that ground drunks or men who beat their wives should be locked up. People with mental problems commit a very small proportion of all serious violence and their detention is therefore discriminatory.

The illusion of safety

Professor Szmukler identified another problem. Homicide and suicide are so rare that they are impossible to predict accurately. The risk of mild violence in patients with psychosis is six in 100. For serious violence it is two in 1,000. For homicide it is one in 15,000.

"These are incredibly rare things – no test could be sensitive enough to pick up such rare events without falsely charging dozens of others," he said. "Let's concentrate on alleviating suffering, not on the illusion of risk management."

Care or control is the theme that has run through mental health policy for the past 200 years. Do we look after them or lock them up? On the one hand the Government has shown its commitment to increasing funding, reducing stigma and coercion and providing a more supportive service. On the other it has revealed a determination to clear the streets and make the taking of medication "non-negotiable" – a zero-tolerance, authoritarian approach that will deter users from approaching services.

The most effective way to improve the safety of the public and the care of those who are mentally ill is to devise services that genuinely engage users. If, instead, politicians pander to public prejudice, they will drive people away from services and increase the risk of further tragedies.

'Pure Madness' by Jeremy Laurance is published by Routledge, £45