This might seem like an irrelevant question, coming from a forensic psychiatrist, but it is something that a small group of us is wrestling with as we work at the Royal College of Psychiatrists to re-write the curriculum for higher training in Forensic Psychiatry for England, Wales, Scotland and Northern Ireland.
Several key themes about the work emerge. We don’t provide care only for Mentally Disordered Offenders (MDOs) because many of our patients are never prosecuted/criminalised. We care for people who are MDOs and also for those who present a risk to others. Most patients present a risk of violence (which is not necessarily direct physical violence) whilst some present sexual or other risks to others. Many also present a risk to themselves.
We work with other professionals to identify and manage vulnerability. Our patients are vulnerable and so, often, are their families, carers and other acquaintances. They are sometimes vulnerable because the patient’s risks make them vulnerable, and sometimes vulnerable because of the many, many factors that contribute to our patients’ difficult circumstances.
The secure environments (clinical and non-clinical) our patients and staff find themselves in can increase vulnerability – for patients and staff, but also reduce it. A few years ago it became clear from published, peer-reviewed research that the health of people received into the prison system actually improved in the month after they were received there.
In-patients in secure hospitals are either non-smokers or become ex-smokers on admission, because smoking is prohibited and actively prevented. Does this mean that life expectancy increases as a result? Some patients function better in this secure environment, free from illicit drugs, tobacco and the challenges of the outside “real world” better than they have at any point in their lives – but only a minority want to stay longer then they are legally obliged to. Sadly, some never want to leave.
Forensic psychiatrists have a duty to motivate clinical teams and focus on the positive – celebrating sometimes small gains made by patients and ensuring that the team, and the patient, never lose hope – whilst remaining realistic.
Forensic psychiatrists work in a range of environments, including prisons, immigration detention centres, secure children’s homes and other places, where they have little power, but retain a duty of patient care, to promote and advocate for a health-promoting, positive therapeutic approach when the aims of the institution may be quite different, such as containment or even punishment. It is vital that forensic psychiatrists remain doctors first and foremost, and ensure that their ethical, patient-centred focus is preserved and asserted whenever necessary.
Attention is often focussed on the more obviously modifiable risk factors – psychological and social factors and these are important. Primary prevention also needs to bear in mind the less obvious. Adverse experiences modify gene expression in clinical significant ways. There appear to be significant links between the genetics affecting monoamine oxidase (MAO) activity and vulnerability to PTSD following traumatic events. These are common to staff, patients and others and need further exploration.
We often talk about risk assessment and risk management. What about harm prevention and threat assessment? What role should we expect forensic psychiatry trainees and newly qualified Consultants to play in identifying and challenging false economies and service developments that lack an evidence base or, even worse, may appear to be actively harmful to our patients, staff and the wider population.
No curriculum is ever going to answer all these problems, but working to re-write a curriculum provides plenty of food for thought and a valuable opportunity to take a step back to think about, discuss and debate the ways in which many foundational areas of our small but important specialty can contribute to more effective and safer care for our patients and potentially lead to longer, safer and happier lives for our patients, staff and the wider population.