Managing Clients with Psychiatric Disorders

Preface

“It is ironic that the law and mental health professions, two of the disciplines most concerned with the meaning of language, should have so much difficulty in agreeing on the meaning of many of the key concepts and phrases in their ongoing dialogue about how best to deal with the mentally ill. Unfortunately, a number of ‘catchwords’ have entered the legal-clinical dialogue, becoming in practice a sort of shorthand but frequently serving to interfere with, rather than to facilitate, effective interdisciplinary communication.

“Both professions use the various terms with approval; but as they have very different meanings to each, the apparent agreement in fact serves as an obstacle to collaboration, and it is confusing to those (such as members of courts and legislatures) who must arbitrate disagreements between the two groups.” (R Miller in P Shea Psychiatry in Court, 1993:xiv)

Introduction

There will be as many opinions in this room regarding psychiatry as there are people. The things that we can discuss at the borderline between your discipline and mine are so extensive, I believe, that we ought to breakfast now because we will still be going at that stage.

There is an important disclaimer. Criminal activity is no more likely to occur within the mentally ill population than it is in the general population. The presence of a mental illness in a person does not predispose to crimes against persons or property. There are occasions when the abnormal mental content of an ill person will result in a causal relationship between the mental health status of that individual at the subject time and some unlawful act.

In more general terms, and in line with the Law and the guidelines regarding evidence in mitigation, every crime occurs in a psychosocial context. Often, it is important for the Court, within the limits presumably of what is more probable than not, to know of the psychosocial context and the relevance of the person’s life course to a particular event.

With modifications, the same thing can be said about the psychosocial backdrop to an accident in the workplace. In fact, it is often more complex in that situation because in my experience there are often factors within the life course of the employing entity that are relevant to a particular accident. There is the old story about accidents, particularly road accidents, where it requires two people to make a mistake at the same time for an accident to occur.

Health Gatekeepers

There are non-medical people within the community who have substantial contact with the public and experience in dealing with members of the general population in all types of situations, be it crowd control at a liquor-licensed venue or police patrolling a local park. The mental health gatekeepers, to my mind, include police, clergy, and legal professionals amongst others because these groups all have training in observation and substantial contact with people. It is important that these people exercise that function so that people who are sufferers in the true sense because of mental health harms are directed towards help rather than being placed in situations of deprivation where further trauma and loss of trust in human nature occurs.

Presentations of People with Mental Health Harms to Professionals

The obvious presentation: There is a threat made towards the self or towards the other.

The non-obvious presentation: Serious mental illness can present covertly. A depressive person can present with normal behaviour and even the usual smiling and other social responses and gestures. Many people with mental illness hide their suffering or they use their intelligence to swap types of suffering. An example of this would be a person with severe Generalised Anxiety Disorder who self-treats with alcohol or the young man with a history of ADHD and a history of inappropriate prescribing of psychostimulants by neurologists and psychiatrists who presents later with a methylamphetamine addiction, all related to an underlying and undiagnosed depression.

Similarly, many of the heroin addicts begin life as highly anxious or severely depressed or psychotic people with the illness of schizophrenia.

Presentation out of left field.

Assaultive behaviour directed at an individual or directed at groups of individuals within public places or within buildings.

Colleagues in trouble with their mental health.

* Early signs
* The suicidal colleague
* The colleague who is developing professional problems

Principles for Handling Overt Aggression

The non-reciprocal approach to threat of violence.

A violent man is a frightened man and how this helps you.

Office architecture.

Office crisis plans.

Self-defence, bearing in mind that the best self-defence ever invented was running away.

Your Health and Safety Responsibilities to Your Support Staff

Health workplace.

Safety of staff.

Issues:

* Duress alarms
* Fire drills
* Evacuation plans to deal not just with fire but also to deal with behavioural dangers and violence
* Procedures for warning neighbouring staff and offices

Bear in mind that this issue is very much like boating safety. If the equipment is there, it is there when you need it. If no plan exists at the subject time, a crisis is not the time to be inventing a plan. The other issue with planning is that the colleague next to you will have no idea what you are likely to do unless there is a plan in place, everyone is aware of it, and there is at least some chance that some of the people will keep to the plan.

Legal Professional Management of Cases with Medical-Psychiatric Components

As professionals, you will all have your own preferred methods for dealing with this issue if you recognise it as an issue. The contribution being made here is only one view and all of us have different practices depending largely on how we self-select our client base. This, in turn, means that we all have differing experiences of our professional practice, even within the same professions.

The Australian National Mental Health Survey

“Mental illness is out there” – The Australian Mental Health Survey

This survey was conducted by the Australian Bureau of Statistics in order to provide a detailed overview of the prevalence of mental and substance-use disorders for Australia by way of a 1997 Australian national survey of mental health and well-being. This was the first Australian national household survey to replicate and extend the 1990 United States national comorbidity survey of adults aged 15-54 years, published in 1994, and the 1993 United Kingdom survey of psychiatric morbidity in adults aged 16-64 years, published in 1997. All of these surveys aimed at three questions:

1. How many adults in private households suffered from mental disorders?
2. How disabled were they by their psychiatric impairment?
3. What health services did they use and want?

In the Australian survey, close to 23% of adults reported having at least one psychiatric disorder in the previous 12 months and 14% were suffering from a disorder when interviewed. Only 35%, or about one-third of people with a mental disorder in the 12 months prior to the survey had actually consulted about it as a defined problem and most had seen a general practitioner, not a specialist. 50% of those disabled or having multiple comorbidities had consulted. The Australian survey divided up mental disorders under affective or mood disorders, anxiety disorders (and these included any anxiety disorder including PTSD), substance use disorders (which included licits and illicits and any harmful drug use/abuse), and then under other disorders they placed the personality disorders, cognitive impairment, and psychosis which did not have a category of its own.

About 1 in 6 people in the Australian community met criteria for any disorder during the prior year and 1 in 11 met criteria for active illness during the months preceding the interview. The other disorder section included a screen of questions which identified other neurotic disorders in 1.5% of the sample, personality disorder in 6.5%, cognitive impairment including early dementia in 1.3% of the sample, and active psychosis in 0.4% of the sample. Thus, the total prevalence in the year was 22.7% using the International Classification of Diseases 10 (ICD-10) and 20.3% using the Diagnostic and Statistical Manual (DSM-IV).

Women had higher rates of mood and anxiety disorders and lower rates of substance use disorders in contrast to men. The elderly had lower rates for all disorders except cognitive impairment. The young had much higher rates of substance use disorders. Currently married had lower rates for all disorders in contrast to those never married or presently separated. Disorders were more frequent generally in those with less education. Similarly, those who were employed had lower rates for all disorders. About 4% of people admitting to suffering from conditions suffered from 2 or 3 or more diagnoses at the one time (ie comorbidity).

Your browser may not support display of this image.

Suicide

Suicide is the leading cause of death amongst adult offenders in custodial settings. Inmates are up to ten times more likely to die from suicide than their counterparts in the general population. Custody-related deaths may account for up to three-quarters of all deaths amongst custodial clients who have not yet gone to trial and up to one-third of all deaths amongst sentenced prisoners. In 2003 there were some large English studies from England and Wales. One study looked at non-fatal suicidal behaviour and found that over one-quarter of male prisoners on remand had attempted suicide in their lifetime and one-sixth had done so in the past year. Half of the female prisoners on remand had attempted suicide in their lifetime and over one-quarter had done so in the past year. In the week prior to the interview, 23% of female prisoners had thought of suicide. Those who attempted suicide were in poorer general and mental health.

Mortality was examined in a twelve-year follow-up of 3000 young offenders undergoing their first custodial sentence in Victoria, Australia, in 1998-1999. The overall risk of death from any cause was nine times higher amongst male young offenders. 23 suicides occurred, 22 being males comprising 24% of all deaths.

During the opening of a new prison in Scotland, there was an opportunity to look at the additional workload placed on the local emergency department. During the first year of life of the new jail, 22% of 103 emergency transfers for treatment were for deliberate self-harm. This was the major cause of emergency medical transfers from the prison.

The Simple Mathematics of Diagnosis

The simple mathematics for diagnosing mental illness and for predicting that all practitioners dealing with the public will have contact with mental illness regardless of whether it is relevant to a particular case management situation.

If it is appropriate to involve a mental health professional in case management, be it criminal or personal injury work, the early involvement of the psychiatrist or psychologist is probably more useful than late involvement.

Examples.

Survey of Last 100 Medicolegal Cases

The Medical-Psychiatric Intervention at Legal Practice Level

Early detection is better. This leads to early involvement of colleagues from other disciplines.

The other professional, psychiatrist or psychologist, will conduct some form of standard interview or examination with or without psychometric testing.

Substantiation of expert opinion is of importance to the Court. Professionals from other disciplines do not understand how facts are established at Law and how the medical-psychiatric reporting ought to relate to facts or to peripheral issues which are more probable than not.

The quality of the brief is important in terms of informing the colleague. The commissioning letter is vital. How a relationship begins usually determines how it ends. The commissioning letter should state the conditions of the commission and the questions which the legal professional wishes to pose to the other professional.

The question of professional fees for the person doing the work that you required is an important issue around which difficulties can occur. The Courts and the professional colleges, as I understand it, look with favour on reporting where the contents of the report are not linked to the payment of the report. This brings up the issue that the College of Psychiatrists, as far as I am aware, certainly considers that payment should be required before the report is handed over. It is appreciated that the professional costs of the consultant are actually the responsibility of the client of the solicitor and for the solicitor to indicate in the commissioning letter that he or she is responsible for the reasonable costs of the consultant is probably meaningless. If you have a relationship with a professional that you value and you wish to keep it, this issue needs to be cleared up. It may well be that you can clear it up simply by getting a quotation from the professional for the work, deciding whether it is reasonable, finding out under what circumstances it would be discounted, and then requiring your client to place funds in trust against the provision of that report.

It is absolutely important that the commissioning letter poses the questions that you require to be answered. From your viewpoint, you think it is quite obvious. For those of us outside the Law, unless we have done a lot of this work and are talking to many legal professionals, we have not got a clue what you really want. One good example of this is the issue of vicarious experience and complicated grief and what is required, in terms of personal injuries work, to establish that a person has suffered a deep personal loss but has not suffered a normal bereavement.

I think too that you need to explain to the non-legal person aspects of Expert Evidence and what substantiation will be required to meet the requirements of rules for experts which are continuing to evolve.

A personal and family history together with a plea for mercy in the last paragraph is not a psychiatric or medicolegal report. Many medical people are quite phobic about Courts. What you will get from them is a defensive report which becomes more of a personal reference and something far less than an expert report. I believe that the legal mind should be kept open to sources of extra information, both in terms of case management and also in terms of assisting the expert to substantiate the arguments in mitigation or to substantiate the complaints of the injured worker. I am still waiting to have a videotape played to me of a patient with medical and physical disabilities loading concrete blocks onto a car or doing roofing, but I am sure it will happen one day. Extra information is a good way of assisting the professional to obtain consistency and verification of the self-reporting.

Ultimately, self-reporting is like painting a canvas. The individual has inside his or her head a picture which is an artistic creation of the self. For personal reasons it is required to get this picture onto the canvas and have it look the way that it does on the inside. The picture as painted will have some resemblance to what is happening on the inside of the patient and may tell you a lot about what is happening on the inside but tell you very little about the matter which is being dealt with by the Court.

References

Andrews G, Henderson S, and Hall W (2001) ‘Prevalence, Comorbidity, Disability, and Service Utilisation: Overview of the Australian National Mental Health Survey’ British Journal of Psychiatry, 178, pp145-153.

Henderson S, Andrews G, and Hall W (2000) ‘Australia’s mental health: an overview of the general population survey’ Australian and New Zealand Journal of Psychiatry, 34, pp197-205.

Shea P (1993) Psychiatry in Cour,t Sydney: The Institute of Criminology.

Stuart H (PhD) (2004) ‘Suicide in Custody’ in Fast Facts – Psychiatry Highlights 2003-04 Malcolm Lader (ed), Oxford: Health Press Limited.