Mental health, violence and assessing risk: liability of psychiatrists

24 Dec

Mental health & violence has been all over the media recently. I’d like to be writing about something else, but the subject keeps cropping up.France psychiatrist screenshot

This time, it concerns a psychiatrist in France, Daniele Canarelli, who was given a suspended jail sentence for a murder carried out by her patient, Joel Gaillard. We know very few details of the tragic case, but it has prompted discussions, like the one below, about how mental health professionals should assess and act on perceived risks.

As I tweeted on Sunday:

“How do you balance risk and recovery? How do you know when to detain and when to release? When to encourage and when to warn?”

(I should add that I have very limited knowledge or experience of criminal law or forensic psychiatry but it seems, following my experiences last year, to be something I’m slowing getting to know more about. Not something I’d ever anticipated.)

In the real world, such balancing acts must, I am sure, take place every day: when a police officer decides whether to detain someone under s.136; when an AMHP decides whether to detain someone being assessed in their home; when a psychiatrists decides whether to release a patient from a secure ward; when a mental health professional decides whether to warn the police that their patient may be dangerous.

In this tweet story, three tweeps – a senior police officer, an AMHP and IMHA working in forensic services – discuss this difficult case and its potential ramifications. Inspector Michael Brown (@Mental Health Cop), AMHP “BC” (@444blackcat) and Rob Jamil (@robjamil) (IMHA and trainer working in forensic services) are those 3 people. “BC” could be the person making decisions about detention during a psychiatric assessment in the community. Rob Jamil could be the person helping the patient detained on a criminal ward get his voice heard about his stay on the ward. Inspector Brown could be involved in the investigation of a murder.

The fear expressed by Canarelli’s defence lawyer was that, by placing criminal responsiblity on the shoulders of clinicians in this way, psychiatrists would be forced to take the least risky option. And that the fear of criminal prosecution would weigh against the wishes of the the patient to get on with their life and indeed the benefits to the patient of doing so.

It’s important to bear in mind that this is a case in a different legal system to our own. And that very few murders are committed by people with mental health problems. As consultant psychiatrist Trevor Turner is reported to have said in this Guardian article (which is the subject of this blog post on the use of the phrase “normal people”):

“In the 1950s, there were about 100 murders a year, of which 30-40 were committed by people with mental illnesses at a time when 150,000 people were locked up in asylums. In the 1990s, said Turner, there were about 750 murders a year, but the numbers committed by people with mental illness remained at 30-40, even though the norm was by then care in the community and the asylum population had dropped to about 30,000. The conclusion, said Turner, is that “the rate of murders by normal people has climbed inexorably”.”

There seems no justification in fact for the public’s fear of violence carried out by people with mental health problems. Let’s hope psychiatrists won’t develop an irrational fear too in the wake of this recent French case.

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Jargon buster:

  • AMPH: Approved Mental Health Professional
  • IMHA: Independent Mental Health Advocate
  • Forensic services: services involving crimes and criminals

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