"I have had to watch the decline of academic forensic psychiatry in this country"
My name is John Gunn I am a retired forensic psychiatrist and I've been asked to write a blog about what I do and why I like it. The word forensic simply means legal; therefore a forensic psychiatrist is someone who specialises in the management of patients with legal problems, usually offenders. It has nothing to do with pathology or dead bodies.
Being a psychiatrist is an immensely satisfying job; it is concerned day in day out with people in various forms of mental distress. There are a variety of mental disorders such as schizophrenia, bipolar disorder, mania, depression, anxiety, panic attacks, phobias, drug taking, behaviour disorders and so on. Many of these conditions are life-threatening but many of the conditions are also eminently treatable.
Forensic psychiatry focuses on disordered people who find themselves in conflict with the law. Some are very impulsive, others are violent, some are driven by insatiable deviant and illegal sexual needs, for example, some have a desire to have sexual activity with children. Much antisocial behaviour arises from a disturbed childhood, frequently an abused childhood. Disorders of this type can be seen as existing in a vicious circle; abuse leading to damage and damage leading to abuse. The role of the forensic psychiatrist is therefore to identify disorders that will lead to legal conflict and prevent them wherever possible, and if necessary provide treatment after the event in the case of, say, a violent outburst or illegal sexual activity.
Psychiatric beds in hospitals have been severely reduced in numbers in my lifetime. It has been thought to be cruel and unreasonable to detain people just because of their mentally disordered thinking. It has also been thought that short periods in hospital followed by long-term treatment in the community is the best way to manage almost all psychiatric conditions. However, most people want antisocial behaviour contained in some way and hospitals with facilities for treating people with antisocial mental disorders have actually increased in number during my lifetime, but investment has not kept up with demand and there is always a shortage of beds, doctors and nurses in all branches of psychiatry.
The satisfactions of treating someone who is in great distress or who has had their life seriously damaged by their thinking and their behaviour is, are enormous. It is doubly satisfying if it is apparent that the patient can have both their symptoms relieved and also their behaviour changed so that they become safe to other people. An outpatient clinic of previous offenders, who are now keeping within the framework of the law, even though they may have residual symptoms and even though they may find work and accommodation extremely difficult, has been a very rewarding experience for me for many years.
Working with offenders means that the forensic psychiatrist collaborates with, not just the usual health professionals that all psychiatrists work with, such as nurses, social workers, psychologists and occupational therapists but also lawyers in advising them how to deal with cases that come before the courts, and police officers who manage threatening and dangerous behaviour. For example, I and my colleagues were retained for some years by to the Metropolitan police to give advice about the management of siege situations in which a very distressed individual is threatening to kill other people, often members of his own family. Domestic violence comes within the purview of forensic psychiatry but is rarely seen as a top priority health issue even although many of the murders and the suicides in Britain are related to domestic conflicts and are extremely costly both in emotional and in financial terms.
Not all forensic psychiatrists are academics, but I always had an interest in research and teaching and took up academic posts at the Institute of Psychiatry for most of my career. My first substantial research was to conduct a survey of people in prison who also had epilepsy. At the time I did this in the 1960s it was widely believed that people with epilepsy were more likely to be violent than other citizens. My survey did indeed show a larger number of individuals in prison with epilepsy than one would expect by chance. However, it became clear that this was not due to people with epilepsy being especially violent or indeed especially criminal; it was the other way round, people who were at the bottom of the social spectrum, and in addition had the horrible disease of epilepsy, were more likely to be institutionalised in one way or another than other people.
This study led me to a lifelong interest in prisons, which tend to be our forgotten institutions. Originally they were built as holding places for people who were to be executed or transported. As liberal ideas gained traction in the community the prisons became places of punishment in themselves and right up until the Second World War they were institutions where cruel punishments were handed out fairly freely; punishments such as solitary confinement, lashings, bread and water diets and, in the case of murderers, execution. This all began to change as I was taking my first interest in prisons and slowly, until very recently, they developed a strong rehabilitative and therapeutic role for people with antisocial behaviour. Recently this progress towards rehabilitation has been several damaged by cuts in resources.
It's not true to say that people have ever been sent to prison for treatment. Anyone who could show the main problem was a psychiatric one should have been, and on occasions was diverted to a secure psychiatric hospital. However, many mentally and some physically disordered people were not able to receive NHS treatment due to a lack of appropriate investment. One really big problem for people who get themselves into prison is what one might broadly term self-medication - the taking of illegal drugs, and probably even more commonly the taking of our favourite legal drug, alcohol. All these substances damage the brain and produce abnormal and antisocial behaviour. Part of the function of any therapeutic approach is to try and wean individuals away from these substances, although it is very difficult because even within the prison walls most brain damaging substances are freely available.
Prisons, during my lifetime even developed psychiatric treatment in the form of either individual psychotherapy or in a therapeutic community. These our rare resources are nowhere near sufficient to deal with the numbers of people who need them. More recently psychology services have been introduced into prisons and they attempt to treat people with impulsive behaviours but particularly with deviant and aggressive sexual drives. The other group of people forensic psychiatrists work alongside our probation officers. Some offenders can be sentenced to probation rather than imprisonment and during their period of probation they will be attended to by a probation officer who sees them regularly and tries to advise them about ways of keeping out of trouble.
As I mentioned above austerity has damaged the rehabilitation work which prisons in England were undertaking. When Christopher Grayling was appointed as Minister of Justice he decided to drastically reduce the numbers of trained and skilled prison officers. This has had the predictable effect of increasing prison violence both to other prisoners and to staff, increasing the suicide rate of prisoners, damaging or stopping treatment programmes, and generally making prisoners more likely to commit offences. It also produced an upsurge of illicit drug taking which made the prisons even more unmanageable and led to riots. Not only did he do all this but Mr Grayling also privatised half of the English probation service so that staff and prisoners on prisons and probation and parole were handed over to inexperienced profit making private companies. As Richard Ford in the times on Wednesday, 2 August 2017 told us the number of offenders charged with murder or other serious violent crimes whilst under probation supervision has risen by 25% since the partial privatisation of the service. The Ministry of Justice has also had to pay a bailout of £21 million to some of the privatised community rehabilitation companies. All this in the name of "economy" and "deficit reduction". Special education classes for politicians might produce a better result.
Since I have retired I have had to watch the decline of academic forensic psychiatry in this country. Neither the universities nor medical charities have taken an interest in the serious reduction of research and teaching related to this specialty. Professorial chairs set up at the end of the last century and now lying vacant. In an attempt to highlight this problem and to raise some funds for academic forensic psychiatry, especially research in this vital area, my wife and I have set up a new charity Crime in Mind which aims to raise funds and public interest in this work. To recover even the position which pertained in the 1990s is a daunting and uphill task but we believe it is essential if money is to be saved, crime is to be reduced, and humanitarian medical developments are to continue for a very unpopular group of our citizens who suffer from very complex needs.
If you would like to donate to Crime in Mind you can do that here: http://www.crimeinmind.org/donations/4588369818