THE PRESS MONDAY, SEPTEMBER 3, 1984. Care of dangerous patients

Press, 3 September 1984, Page 20

THE PRESS MONDAY, SEPTEMBER 3, 1984. Care of dangerous patients

The law and psychiatric medicine are often uncomfortable bedfellows. In many court hearings, an accused’s state of mind, his sanity, the extent of mental disorders from which he may or may not suffer, are the source of divergent — even contradictory — arguments from experts called to give evidence for the defence and for the prosecution. Such instances in the courts highlight the difficulties of assessing psychiatric illness. No less difficult is deciding how - best to detain potentially dangerous psychiatric patients so that the safety of the community is guaranteed, and the welfare of the patient is catered for, without arbitrarily cancelling the protection of rights and freedoms that the law extends to even the meanest criminal.

The difficulty was highlighted last month in a decision of the Court of Appeal which ruled that mental patients should not be prosecuted for escaping from psychiatric hospitals. Psychiatrically disturbed prisoners, those who were once known as the criminally insane, are and always have been a problem. Society has been unable to find a response to them that is at the same time appropriate, adequate, and humane. The continuing spate of patients absconding from Oakley Hospital in Auckland has drawn from the Minister of Health, Dr Bassett, the view that a new, secure place for disturbed offenders is needed urgently. Meanwhile, the security at Oakley will be tightened, not for the first time. Dr Bassett seems to suggest, however, that he accepts the inevitability of a third tier of institutions to deal with those people now left in limbo. The essential problem was recognised more than a century ago. In 1882 the New Zealand Inspector of Prisons said in his annual report: “The question respecting lunatics and inebriates being placed in prisons or hospitals ought to be settled once and for all. It has been, for 10 years, a case of each institution refusing to take them in.” The issue is little closer to resolution today. Prison services are not properly equipped to deal with the psychiatrically disturbed, and hospitals are no longer the secure asylums of a generation ago. The gradual change in the.treatment of patients has meant that arrangements which worked previously are no longer appropriate. What has developed is a substantial grey area for which the Justice Department and the Health Department would happily decline responsibility. This is not merely a desire to avoid a difficult or unpalatable dilemma. Neither department can cater/or these people properly at present. They are people whose criminal activity is attributable to mental ill-health. They may be known to be violent, or violent at times, and may have proved dangerous to themselves or to others. Some are potential suicides and may be disruptive when in prison; such people can be grave security risks when in hospitals and an unhelpful affliction for nursing staff whose work is impaired by having to adopt the mantle of jailers.

Though the problem is not new, it has become more urgent because the number of patients shows signs of growing. Perhaps the pressures of the modern world have contributed to this growth; the increasing abuse of mindaltering drugs certainly has had its effects. The bridge between psychiatric hospitals and conventional prisons requires more than tinkering with what is on hand; the third group of institutions hinted at by Dr Bassett was the solution recommended by a working party of the Justice Department three years ago. Providing these institutions poses a greater problem than finding the money to build and staff them, difficult enough though this might be. The new group of institutions will also require the definition of a new group of psychiatrically disturbed prisoners and of their rights and restrictions. The General Election interfered with the passage of legislation that would have gone a long way towards this. The former Minister of Justice, Mr McLay, and the former Minister of Health, Mr Malcolm, had promised legislation that would have given effect to the recommendation of a 1983 Commission of Inquiry to create a new category of psychiatric hospital patient, that of “restricted person.” The former Cabinet had agreed in principle that a new class of institution was needed to accommodate these people.

It had been intended that an advisory committee, mainly of psychiatrists, but including the Secretary for Justice or his nominee and a lay member, would decide whether persons referred to it should be designated “restricted persons.” This poses a problem. The need is to identify a high-risk group without placing unnecessary restrictions on a far larger number of patients who are of no actual or. potential danger. In practical terms, the difficulty in identifying a person who might present significant dangers to the community — without incorrectly labelling a much larger group who do not pose a danger — is even more problematic than the difficulty in deciding a person’s state of mind at the time of an offence committed some time in the past. A further problem is posed by patients who are troublesome, rather than troubled, and yet no obvious danger to themselves or to the community.

Dr Bassett is right to concern himself early in his term of office with the issues raised by the escapes of psychiatric patients from hospitals. He has acknowledged the very real alarm in the community that absconding patients have committed serious offences while at liberty. He will have on hand the Justice Department report and the recommendations of several commissions of inquiry to help him, as well as another review by a committee of officials from the Police, Justice, and Health Departments that reported earlier this year. There should be no need to delay action with more words. Even the restraints that the Government has on spending should not prevent him coming to grips with this difficult problem.