Hard cases make .....

M ental I llness C oncerns A ll	The Chair intended for this Inquiry was Professor Geneva Richardson. She went off to assemble and to carry forward a Committee examining and preparing the possible options that the prospective new Mental Health Act might bring to bear on difficult to manage people who behave badly in the community. This particularly saga would have fully tested her task. And her Committee recommendations may have steered a different course For this is an unanswered problem left to the future It is a most satisfying saga, an exemplary Report, fully worked out, very readable and helpful, detailed, reticent yet compendious, with a final appendage which invites a stroll in the jungle of definition. The Inquiry is a very extensive look at the problems thrown up by an incoherent system of care service meeting a psychopath. Required reading for anyone contemplating a new mental health Act. There is a long history of frequent childhood misdemeanours - conduct disorders , including arson. The first adult service is a local psychiatric clinic referred there by adolescent psychiatric service who were concerned about his emotional state 'after the death of his natural father two days previously'. B. had cut his wrists. He told on this admission of having been in contact with his natural father between six and sixteen years, since when he had not seen him. he learned from a friend of his father's death from cancer. [ although many times what B. says about his family and himself is untrue, the Report does not challenge or confirm the truth of this initial account of a relationship with his natural father - but we never hear of it again. Only the mother is a family witness to the Inquiry ] He reported having been unemployed for three years, before which he had worked in a care home for mentally handicapped ( later 'autistic' - he may have learnt something about the 'professionals' from this ) children 'but could not cope'. He had been under the care of child psychiatrists since aged six, for truancy and running away from home,and said he had lived in a children's Home from eleven till eighteen, when he went to live with his and step-father and their two sons. Bath (B) was not formally mentally ill. It took a little time to be clear about this. He was a great nuisance to the local mental health services, did not respond to their systems, and did not modify disruptive behaviour in their admission wards, which took up time and attention that would otherwise gone to those with mental illness. The mental health services did not know how to deal with someone who would not appreciate what they tried to do, and did not comply or empathise with their offers. He did not stay around long enough to be curtailed and contained. One of the regrets of the Inquiry is that the health systems did not gather everything in so that people knew where they stood with B. Each separate contact worked its way through its own particular episode. No one person in charge drew together a list of those sequential episodes which would be the basis for a category of abnormal personality in active anti-social mode. The term ' psychopathic personality ' is out of fashion, and the term 'personality disorder' does not draw in the same apprehension, nor convey the necessary imperative for pinning down the whole story of the behaviour, in someone who lied and distorted accounts of his life happenings and it's obligations. He had 'the usual' poor childhood experience and poor or broken attachments to exemplary models. He was born by an extramarital meeting, and never knew his own father. He knew this from early childhood and it was likely always brought up by his step father. His mother acknowledged he was generally out of control. He had a younger half brother and an older half brother by a step father who was a difficult character, invalided out of the Army, irascible, physically aggressive within the family, and thereafter 'on benefit'. There was also an elder sister, conceived before this marriage and out of the picture. Their account is not sought. Mother is described as affectionate if feckless, but dressed her schoolchildren well. Bath said she always gave him love. Bath claimed a neighbour sexually abused him. Bath was a defiant child. 'in LASS care after ten years of age'. So were his siblings, more briefly, but they turned out alright if this means managing without mental health services He was partially deaf and at the upper level of 'educationally backward'. He never had any sustained employment skill. The best account of his anti-social beahviour came in the probation assessment, after two or three arson reactions. The local health provision was too patient and too long suffering with someone who took advantage of their tolerance and may have been unhelped by that. Nobody had a full account before them when dealing with various anti-social incidents. He would quickly lose contact, and shift to other ground. They went on saying there was no treatment which would achieve any success. He was not biddable. Both the Courts and the A&E departments met him many times. Those contacts are almost a diagnostic correlation. The prison service and Court systems did not take the mental health assessment route into a secure hospital detention. When very small fires are attended to by different people each one seems hardly enough to warrant a system response. The cost of that seems to be too high. The ultimate conflagration seems unexpected. The prediction of homicide is not possible, except in hindsight. A new Mental Health Act will be tested until confidence in detention for assessment, and in sequestration, returns. A new Mental health Act can lead to the release of those people suffering from schizophrenia, who are in Secure Hospitals after acts of violence committed after stopping or forgetting their medication. Mandatory Community Supervision Orders can allow the release of patients with controlled schizophrenia from secure Units and Secure hospitals. Many are unecessarily there, for years, because there is no confident aftercare under supervision. No menu. They will conform to a new imposition of community direction when the context of the care imposed as a consequence can be seen to bring benefit. Then those secure Unit placements are available to be used as a consequential response to the challenging misbehaviour and challenging therapeutic attachment of disordered personalities - until the capacity to see that consequence is there. Segregation will allow a longer period of challenge to misbehaviour, and decisions about future care which is unhurried, which is not driven by short term relief, and does not resort to the hope that the problems just go away, or will land somewhere else. His victim is a much younger partner who had herself been in the long term Social Care system, and at the time B. first met her, was in a Social Services Hostel. It might have been rewarding to examine how she came to become a victim. Review Weereratne; Bath back to Inquiry linking	E-mail reaction is welcome mica@didgy.freeserve.co.uk