let's get serious about dangerousness

Let’s get serious aboutdangerousness*

JOHN GUNN Professor of Forensic Psychiatry, Institute of Psychiatry,London

Dangerousness is an important topic for psychiatry. Whether they like it or not, psy-chiatrists are expected by the population at large to select mentally disordered peoplewho are dangerous to themselves or to others, and to treat them. (Gunn & Monahan,1993)

In Britain recently we have been dragooned into setting up so-called ‘supervi-sion registers’. On these we are supposed to put the names of patients who aredangerous to themselves or to others and who require special supervision. Thishas been a highly contentious development and indicates that dangerousnessis creating a growing political agenda. Supervision registers in Britain are justone manifestation of this; another is the increasing number of so-called ‘riskassessments’ which forensic psychiatrists are being asked to do by their generalpsychiatry colleagues. Neither of these developments suggests that we areabout to get really serious about dangerousness.

PSYCHOSIS AND VIOLENCE

It is now considered axiomatic, in Britain at least, that psychosis is associatedwith violence. Ten years ago matters were different. ‘Virtually all the workfrom the first half of this century showed that mental hospital patients wereless likely to commit violent acts than the general population (e.g. Ashley,1922; Pollock, 1938; Cohen & Freeman, 1945; Brill & Malzberg, 1962;Brennan, 1964). Later studies showed that the rates for violent crimes amongmental hospital patients appear higher (e.g. Rappeport & Lasson, 1965;Giovannoni & Gurel, 1967; Zitren et al., 1976; Grunberg et al., 1977, 1978).Steadman et al. (1978), however, suggested that the real increase in arrestrates among mental patients lies within a recidivist group (Taylor et al.,1993).

Criminal Behaviour and Mental Health, 51–64 1996 Supplement © Whurr Publishers Ltd 51

* This paper is a modified version of a similar paper published in Walker (1996)

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Our Brixton remand study (Taylor & Gunn, 1984) indicated a much closerassociation between serious violence and psychosis. This showed that of allthe men charged with homicide, admitted over a 12-month period fromLondon and the home counties, some 11% suffered from schizophrenia.Extrapolated this means that we can expect in England and Wales some 50people to be killed each year by other people suffering from psychosis.

Thus, throughout the world many hundreds of people are killed by psy-chotic patients year in, year out. In other words, the age-old fear that patientswho have gone mad might turn violent is probably based on an understandingof the potential horror of psychosis.

The important thing is to keep this in perspective. Saying that 11% of mencharged with homicide suffer from schizophrenia is a very long way indeedfrom saying that a high proportion of patients with schizophrenia commit vio-lence. Schizophrenia afflicts approximately 1% of the population and generalpsychiatrists will meet very few seriously violent schizophrenic patients in thecourse of their ordinary practice.

The important Epidemiologic Catchment Area (ECA) Survey from theUSA (Swanson et al., 1990) has shown that individuals in the communitywith psychiatric disorders are more likely to report engaging in assaultivebehaviour than those who are free of mental illness and substance abuse. Thecommunity base rate for such reports was 2%, but 8% of patients with schizo-phrenia reported violence in the one year of study. The risk of violenceincreased considerably for those people with schizophrenia who also abusedalcohol or drugs; some 30% of patients with the double problem reported vio-lence.

PREDICTION

In the 1970s there was a concerted search for ways of predicting violence. It waseasy to be beguiled by statistical methods; other methods are so much more dif-ficult. It must have been about the same time that week after week on televisionthe man from the Meteorological Office would appear on BBC television togive us a long-term forecast. This was an estimate of the forthcoming four weeksof weather, based on an elaborate and minute statistical analysis of the weatherpatterns which had appeared in previous years. The Met Office in London has amassive data bank including many climatic variables over many years. Themeteorologists searched with the aid of computers for weather patterns thatwere similar to the ones currently being experienced, and then they extrapola-ted a future model on the basis of previous experience. It must have been a seri-ous embarrassment for the staff who had to undertake this task to realise that,night after night, they were able to make accurate helpful forecasts for the next24 hours, but the speculations for the next 28 days, based on a comparison ofprevious weather patterns, turned out to be little better than chance or guess-work. Eventually, they gave it up and improved their public image.

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In psychiatry a strange cliché, ‘nothing predicts violence like previous vio-lence’, has sprung up. Where does this notion come from? It is a misunder-standing of statistics. There are a number of studies which have shown that ifa large population of recidivists, whether or not they are considered to bementally abnormal, is divided into those who have committed previous acts ofviolence and those who have not, the group with the previous history of vio-lence will generate more of the future violence than the other group. Forexample there is a Norwegian study (Blomhoff et al., 1990) which retrospec-tively compared 25 patients who were violent with 34 who were not violentafter admission to a psychiatric emergency ward in Oslo. There were no differ-ences between the two groups in terms of age, sex, economic status or livingconditions. There were, however, three important differences: the patients inthe violent group had experienced more violence in the family of origin, hadmore often used non-alcoholic psychoactive substances, and more often had ahistory of violence than the other patients. The strongest association was thelast one. So, the authors concluded that ‘in several previous studies violencehas proved to be the best predictor of violence. This finding is replicated inour study’. This is wrong, they did not predict anything. What they showedwas that their violent patients were more likely to have come from violenthomes, to use illegal drugs and to have been violent before. Useful, unsurpris-ing information, but not a prediction.

So the myth that previous violence predicts violence is constantly rein-forced by retrospective statistical data. The problem is that whilst statistics,which are mathematical extrapolations from group activity, can be extremelypowerful in describing and perhaps predicting group activity (although thatneeds to be tested prospectively, not retrospectively), they cannot tell uswhich members of which group will do what. Actuarial assessors can predictwith remarkable accuracy how many children will be born in my country nextyear. They can also predict with remarkable accuracy how many people willdie, and at what ages. However, it is not possible to say with anything like thesame accuracy who will bear the babies and who will die. So the actuarial accu-racy is not of much value if the question concerns a particular individual.‘Will my daughter become pregnant?’ is not a question that most people wouldwant to answer by turning to a statistical table. Nor are they very pleased ifthe doctor attending granny refers simply to statistics when a prognosis for herlife expectancy is sought. In these individual situations, we have much richerdata and for psychiatry we have the amazing power to determine something ofwhat is going on in someone’s head by conversation.

A second myth about prediction is that psychiatrists are no good at pre-dicting dangerousness. This is partly derived from the overworked case ofJohnny Baxstrom. In 1966 Johnny Baxstrom was held in New York’sDannemora State Hospital for the criminally insane. He had been convictedin 1959 of assault and sentenced to imprisonment. Whilst he was serving hissentence he was diagnosed as mentally ill and transferred to Dannemora, but

Let’s get serious about dangerousness 53


when his sentence expired in 1961 he was retained within the hospital as con-tinuing to be mentally ill. In February 1966 the US Supreme Court upheldBaxstrom’s petition, stating that he had been denied equal protection underthe Fourteenth Amendment. He was released. The New York StateDepartment of Mental Hygiene decided there were 966 other patients whocould also petition against detention, so all 967 patients within Dannemoraand Mattewan (the state’s other hospital for the criminally insane) were trans-ferred to civil mental hospitals between March and August 1966. This causeda great deal of anxiety because these patients had all been labelled dangerous.Steadman and his colleagues followed up these cases (Steadman & Keveles,1972; Steadman & Cocozza, 1974). Four years later about half remained incivil mental hospitals, 27% were discharged to the community and 14% weredead. Only 3% were in a correctional facility or hospital for the criminallyinsane. In all there were 16 convictions sustained by a population of 246patients during the follow-up period. The 16 convictions involved only ninepatients, and only two of the 16 convictions were for felonies.

If psychiatrists are asked to make predictions about behaviour over longperiods of time, they are bound to be wrong quite often and they are bound,given their responsibilities, to be cautious about the predictions they makeand over-predict rather than under-predict. Yet, like the weather forecasters,whilst they often get the long-range prediction wrong, they are not bad atthe short term. That will do for me; I don’t need to know whether I shallneed my umbrella in a month’s time, I need to know whether I need it with-in the next 24 hours. Similarly, although this may not seem so obvious,whether Bill Bloggs is going to be violent again in three or four years’ time,or even within the next six months, is much less important than whether heis going to be violent in the next week or two, before he comes back to myoutpatient clinic.

Furthermore the psychiatrist is in a much better position than the meteo-rologist. The weather man cannot influence the weather, but the psychiatristcan influence the dangerousness of his patient. So let’s forget about predic-tions, let’s go to management. Psychiatrists are professionals who can and doon occasions manage dangerous patients quite successfully. They do notalways get it right and some of them are hopeless at it, but within the body ofpsychiatry there is knowledge and expertise about the management of danger-ousness that the layman discerns and wants used more effectively. It is the psy-chiatrists’ responsibility to acknowledge these skills, to refine them and to dis-seminate them.

The refinement of skills will come from research. It seems that for patientswith schizophrenia, length of illness is an important factor (Hafner & Boker,1973) as are age (Taylor, 1993) and the consistent use of antipsychotic med-ication. An important pilot study undertaken on the effects of delusions onbehaviour suggests that in serious schizophrenia many patients, maybe morethan half, actually act on their delusions, some of them violently. The patients

54 Gunn


who do act on their delusions are likely to look for evidence of their abnormalbelief and to be upset by it (Buchanan et al., 1993; Wessely et al., 1993).These phenomena are not predictors of violence, but they are features that areuseful in assessing an individual in just the same way as are his stated inten-tions and his previous behaviour.

Returning to the clinic, how is it possible to assess whether a patient willbe violent in the next week or two? The technique is straightforward. Awealth of information is collected about the patient. Efforts are made tounderstand the way in which his violence potential increases. Interviews areaimed at learning the way he thinks. Does the patient have important ideas,maybe delusional ideas, which are associated with violence? If he is deluded,how distressed is he about this; is he looking for evidence? Is his life frustrat-ing, or is he is relatively content with his social circumstances? Is there another person in his world with whom he is at odds? Does he have the basicessentials of life, such as money and housing? It is possible to draw up a check-list of variables which are important for the routine assessment of risk in anypatient (Table 1).

Assessment merges into management. Changes in the environment(admission to hospital if necessary), medication, home visits, help withfinance and accommodation, useful occupation and the like may all be variedaccording to need.

DISASTERS

If psychiatrists can manage the risk of violence successfully, what is all the fussabout? The current fuss in Britain is that patients with psychosis continue tokill people and quite a number of those patients with psychosis have beenidentified by psychiatrists and are even in contact with psychiatric services at


TABLE 1: Important variables in risk prediction

Demographic factse.g. previous violence, age, sex, marital statusStressorse.g. family, employment, accommodationInterestse.g. sex, violenceContexte.g. potential victims and/or weaponsIntentionsPhysical featurese.g. size, strength, brain functionMental statee.g. anxiety, depression, paranoia, delusion, anger, jealousy

Source: Adapted from Gunn and Monahan (1993)

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the time of the homicide. So what goes wrong? On that point there are data.In Britain we have had a series of highly publicised psychotic homicides. Ofthose available I will choose just two, which illustrate some important points.Dangerousness is not exclusively a male preserve, little has changed betweenthe 1980s and the 1990s, and the lessons that can be drawn from the first casecould have been applied to the second.

Sharon Campbell

The first inquiry is the Spokes inquiry, published in 1988, concerning apatient called Sharon Campbell. She had an extensive history of psychiatriccontact (Table 2). In that contact she exhibited what I increasingly call ‘theusual changes of diagnosis’ (Table 3). The labels in her case ranged fromdepression with paranoid features, to abnormal personality, via an excursioninto ‘no indication of psychotic illness’, into schizophrenia.

Her behaviour first caused concern in 1980 and she was admitted to hospi-tal after nearly causing a serious accident by grabbing the steering wheel of thecar in which she was being transported. Within six months of this first admis-sion she was discharged from psychiatric care with this statement in the notes:‘It is difficult to know whether we are dealing with a paranoid reaction in asomewhat abnormal personality, or whether we are dealing with a case ofschizophrenia’.

Rejection is a powerful predeterminant of violence in many cases, bothpsychotic and non-psychotic. In this case there were professional rejectionsand family rejections. Both 1981 and 1982 were full of incidents, rejection byher family, fires in her room, attacking other people with knives, and readmis-

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TABLE 2: Sharon Campbell: psychiatric care.

June 1980 domiciliary visitadmitted to Bexley (later detained)

September 1980 discharged on leaveOctober 1980 failed OP appointmentsDecember 1980 discharged from careFebruary 1981 drug overdose ‘seemed well’August 1982 re-admitted to Bexley and detainedNovember 1982 discharged to hostelJanuary 1983 failed OP appointmentMarch 1983 visited by social worker (IS)April 1983 attending OPJune 1983 failed referral to forensic psychiatristJuly 1983 still attending OPAugust 1983 left hostelOctober 1983 new consultant – no mental illnessNovember 1983 ‘you might argue how long after-care goes on for’June 1984 visited GP ‘insulting and hostile’July 1984 fatal stabbing of IS


sions to hospital. By the end of 1992 a new social worker, Isabel Schwartz, wasassigned to Sharon’s case. The patient continued to be difficult and to fail follow-up appointments. She objected to medication because she put on a lotof weight and she objected to her new social worker whom she threatenedwith violence. By 1983 she was reported as getting into fights, breaking win-dows, and generally creating work for the police. In October 1983 she madeher first assault on her social worker and questions concerning compulsoryadmission were raised. In her notes was the reassuring statement that ‘thereare absolutely no grounds for compulsory admission’, indeed doctors weregoing so far as to say she was not mentally ill! Instead she suffered from personality problems and social difficulties! She continued to be aggressive toher social worker and started making threatening phone calls to her. Isabel


TABLE 3: Sharon Campbell: diagnoses

June 1980 Depression with paranoid featuresDecember 1980 ?abnormal personality /schizophreniaAugust 1982 ?paranoid psychosis (borderline)

?paranoid personality?schizophrenia

25 August 1982 not schizophreniaSeptember 1982 Personality disorderJuly 1983 Paranoid personality disorder

Severely disturbed adolescent19 July 1983 No psychiatric symptomsAugust 1993 No indication of psychotic illnessOctober 1983 Personality difficulty & social difficultiesJuly 1984 Schizophrenia

TABLE 4: Sharon Campbell: violence

June 1980 ‘always carried a knife’seized steering wheel of carwrist injury (self-inflicted)

February 1981 drug overdoseMarch 1982 fire in a cupboardJune 1982 smashed a windowAugust 1982 chased a resident with a knife

fire in cupboard(October 1982 knife in locker)

OT’s car damagedbroken window (glass fragments)

August 1983 fightsbroken window

October 1983 attack on IS in car(March 1984 telephone threats to IS)May 1983 serious knife attack on residentJuly 1983 fatal stabbing of IS


Schwartz was taken off the case, but the patient’s behaviour continued todeteriorate and she attempted to strangle a fellow resident at her hostel.

On the fateful day, 6 July 1984, she caught a bus back to the mental hospi-tal where she knew Isabel Schwartz worked, and where she knew the socialworker often worked late in the evening in her office. The patient was seencarrying a knife and porters were alerted, but she managed to slip into the hos-pital and wend her way to the social worker’s office. Isabel Schwartz was foundlater dead on the floor, with 39 stab wounds. At that point the diagnosisbecame crystal clear: she had schizophrenia all along and went to a specialhospital.

Christopher Clunis

The second case is the origin of the supervision register mentioned earlier.Christopher Clunis killed Jonathan Zito in 1992. Mrs Zito demanded actionand continues to demand action, having formed her own pressure group andher own charity. An enquiry was held and the Ritchie Report was issued in1994.

An abbreviated history of Christopher Clunis is given in Table 5. A pottedpsychiatric history is given in Table 6, with the usual changes of diagnosisfrom depression to paranoid schizophrenia, ending up in this case with ‘a nor-mal mental state, abnormal personality’.

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TABLE 5: Christopher Clunis: violence

1986 attempted to hit sister1.1.88 hit fellow patientMay 88 found with knife – threatened violence22 May 89 ?attempted strangulation7.6.89 lunged at police with knife2.7.89 threatened to stab another patient6.7.89 threatened to stab another patient29.9.89 punched patient, grabbed a knifeFeb 90 tried to gouge patient’s eye outJuly 90 physical abuse to fellow employees14.8.90 struck resident with walking stick12.3.91 chased residents with carving knife24.7.91 fight with another patient2.8.91 punched nurse, broke glass, attacked patient14.8.91 kicked and burnt another patient27.8.91 severe facial lacerations to another resident23.10.91 punched resident in face3.5.92 set fire to Bible, attacked resident with knife7.5.92 hit duty solicitor7.10.92 tried to hit GP9.12.92 hit stranger in face, chased boys with screwdriver17.12.92 killed Jonathan Zito with knife


Christopher Clunis, at the time Isabel Schwartz was being killed by SharonCampbell, was a relatively well young man who played guitar in a pop group.The death of his mother precipitated a visit to the West Indies and he foundhimself admitted to hospital there. On his return to England a year later, hestayed with his sisters in Birmingham, but was regarded as noticeably odd, col-lecting lots of rubbish and staring into space. A further admission to a mentalhospital in England also resulted in a diagnosis of schizophrenia, although 12months later, after his fourth admission, the diagnosis was changed to ‘drug-induced psychosis’ and he was said to be ‘manipulating his condition to obtainadmission’. The Ritchie report says ‘we are very concerned that each episodeof illness was treated separately rather than as part of a continuing illness’.

In 1988 there was a continuation of his wayward lifestyle; he was in troublefor stealing bread, admitted to a general hospital for refusing to eat ordrink,and arrested by the police for exposing himself. In that year he was alsonoted to be agitated on occasions and the first note is made of his habit of car-rying a knife in his pocket. A nine-day admission was followed by charges forburglary, and further brief admissions followed. The following year he wasnoted to be attacking his social worker, and he attempted to strangle her. Justto complete the analogy with the earlier case, he was said in the notes to be‘not sectionable’. This hideous, aggressive misnomer, which has crept intoEnglish psychiatry, means that the doctor or social worker in charge of his casethought there were no grounds for compulsory admission. A month after thathe was attacking police officers with a knife, but they did not charge him withany offences because they recognised he was mentally ill.

A month after that, he attacked another patient with a knife and stabbedthe patient five times, and once again there were no charges. This time thepolice were not even called. A couple of months later he was in trouble forhitting a woman in the face, and then at the end of the year he was dischargedto the outpatient clinic. He failed to attend, but there was no attempt made toseek him out and ensure the continuation of his medication. The next year he


TABLE 6: Christopher Clunis: diagnoses

1986 paranoid schizophrenia29.6.87 schizophrenia with negative features2.7.87 schizophrenia or drug induced psychosis24.7.87 depression1.1.88 drug induced psychosis, or manipulation for a bed29.3.88 psychotic or schizoaffective illness3.5.88 schizophrenia, drug induced psychosis or organic illness7.6.89 paranoid schizophrenia23.7.91 schizophrenia5.5.92 paranoid psychosis14.8.92 paranoid schizophrenia26.8.92 (diabetes)10.9.92 normal mental state, abnormal personality


was trying to gouge out the eyes of a fellow resident. Later in the year he wasalso in trouble for hitting someone with a walking stick. By 1991 he wasrecorded as refusing to take any medication and in trouble with police forchasing other residents with a knife. A court bound him over in the sum of£500 for that episode.

There is then a complete blank in the file for four months, but he surfacedin July 1991 having been arrested for stealing sweets from a shop. He wasadmitted to hospital, where he stayed for 23 days, but during that time he wasfighting with other patients. He hit a staff nurse. The inquiry team said ‘weare of the view that CC should have been detained under section 3 [that is, acourt order] and nursed on a locked ward’. The story goes on with firesetting,further admissions and frequent assaults. He tried to join a GP’s list, but wasthrown off it when he threatened the GP with a walking stick. All attemptsby social workers to get him to attend an outpatient clinic failed.

By December 1992 he was noted to be harassing members of the publicwith a screwdriver, going up to them saying ‘Are you the devil?’ During thisphase he smashed one man’s glasses and knocked another down. Once morethe police failed to press charges on the grounds that he was mentally ill andthere was nothing they could do about it. Christopher Clunis resolved theintolerable situation himself. Just before Christmas he went into an under-ground railway station, went down on to the platform, pulled a knife andattacked a complete stranger (Jonathan Zito) who was waiting for a train. Hestruck him in the face three times and killed him. He has been sent toRampton special hospital.

Two other tables (Tables 7 and 8) illustrate the brevity of inpatient atten-tion that Christopher Clunis received, and also something of the social factorsin his life. If moving house and changing close relationships are both majorlife events that might precipitate mental disorder, then this brief summary oflife changes between 1986 and 1992 gives some indication of the pressure thatChristopher Clunis was under.

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TABLE 7: Christopher Clunis: length of stay

1986 Bellevue Hospital, Jamaica NK1987 Chase Farm Hospital 25 days, 4 days1988 Chase Farm Hospital 3 days, 4 days

Kings College Hospital 7 daysDulwich North Hospital 9 daysBrixton Prison 21 daysDulwich North Hospital 16 days

1989 St Charles Hospital 110 days1991 St Thomas’s Hospital 21 days1992 Belmarsh Prison 24 days

Kneesworth House Hosp 80 daysGuys Hospital 34 days


These two cases show remarkable similarities. In each case there was a per-sistent reluctance to admit to hospital, probably owing to shortage of beds.Admissions when they occurred were brief. Something else which is clearwithin the reports is that mental state evaluations were very poor indeed. Ateach stage professionals tried to downplay the seriousness of the whole matterand there is a variety of obviously incorrect statements within that vein, suchas ‘no psychotic features’, ‘not ill’, ‘drug-induced psychosis’, ‘personality disor-der’. Violence, threats and cries for help were largely undetected or ignored,and when aggression did occur it was dealt with by rejection.

The Ritchie Report made a long list of recommendations, most of whichawait implementation. Tables 9–11 are a sample.


TABLE 8: Christopher Clunis: accommodation 1986–92

8 hospitals (13 admissions)4 hostels4 bed & breakfasts1 flat2 prisons(35 professionals)

TABLE 9: Ritchie Report (Clunis case): Recommendations A

(1) Better communication(2) Involve patient’s family and GP(3) Obtain accurate history and verify it(4) Consider and assess past violence(5) Plan, provide and monitor aftercare (S.117)(6) Provide assertive care(7) Identify particular needs of homeless patients(8) Police must deal appropriately with the mentally ill

TABLE 10: Ritchie Report (Clunis case): Recommendations B

(1) More medium secure beds(2) More general psychiatric beds(3) A range of health service accommodation(4) More approved doctors (psychiatrists)(5) More social workers

TABLE 11: Ritchie Report (Clunis case): Recommendations C

(1) Do not overlook or minimise violence(2) Provide long term care(3) Do not allow geographical boundaries to interfere with care(4) Do not postpone decisions when patient is threatening and intimidating


CONCLUSION

To get serious about ‘dangerousness’ let us start by dropping the word. It has avalidity, but it serves to mislead. It implies there is a thing or a state that canbe attributed to a patient, called ‘dangerousness’. Steadman et al. (1993) haveurged a reconceptualisation within this field to move the focus away from thelegal concept of dangerousness to the decision-making concept of risk. Theyargue that this would enable decision-makers and researchers to consider pre-diction issues as being on a continuum rather than simply being a dichotomy,and it would shift the focus from a one-time prediction about dangerousnessto repeated day-to-day decisions about the management and the treatment ofmentally disordered people. Let us go even further and shift from the notionof prediction to a notion of risk management. Assessment is not enough. Thedoctor needs to take action to minimise risks as well. A physician, a surgeon,an obstetrician, any doctor, is in the business of risk management. In the casesoutlined, the risks associated with each case were obvious at many points. Theproblem was that the risks in those particular cases were not managed well.

I also believe that we need to change the emphasis of our research strate-gies. We need to understand more of the process of psychiatry to discover whydoctors, nurses and social workers, who are apparently well trained, do mis-manage things on occasions. In the cases described there were whole teams ofpeople missing things, ignoring things and rejecting the patients. There wasgeneral collusion about the strange rejecting, non-medicalising language beingused. We need to research a lot more the problems which face the clinicians,not the problems that face actuarial statisticians. Are these just resource issuesor are there other factors in addition?

The most difficult task, however, is to persuade our political masters to beless dangerous themselves. We now have a situation in which the same gov-ernment that set up the Ritchie and other inquiries is continuing to ignorerecommendations from those inquiries, whilst persisting with, indeed perse-verating with, the same response to homicides, namely the setting up of fur-ther inquiries. At the time of writing there are 24 more in the pipeline! Whatis the point of going over the same old ground again and again? We need totake the matter more seriously. We need to make changes in line with the rec-ommendations we already have. Some of these changes are for the professions,others are for politicians. There needs to be a new dialogue between clini-cians, researchers, civil servants and politicians. All are involved. The publichas a right to expect that we will take the matter more seriously than we do atthe moment.

No doubt the politicians believe that a stream of public inquiries is somesort of ‘action’ that is serious in nature. Instead this strategy has an intenselydemoralising effect on those who are struggling with the problems; it drivespotentially good professionals out of the field, it even makes some profession-als ill, it gives no help to implementing the changes which have already been

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identified as required, and it is close to being a neurotic response. It is particu-larly troublesome as such a response because it gets in the way of more effec-tive research and planned changes, using the knowledge we already haveavailable. At the very least the Ritchie recommendations should be heeded.In addition we might institute new educational programmes for professionalsand we might undertake new research into problems perceived by the doctors,nurses and social workers involved.

NOTE

I dedicate this paper to my good friend and colleague, Professor RobertBluglass. He always sets high clinical standards for the rest of us to emulate.British forensic psychiatry has been different because he was there.

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