The presenters of The Edition, The Spectator’s weekly podcast, are well connected and have real insights into the latest machinations in Whitehall.

James Forsyth, the Editor of the Spectator, often talks on Coffee Shots, The Spectator’s Daily Politics Podcast, about his almost continual contact with senior government figures. If they are thinking it, he is reporting it.

The most pressing issue facing the government, in his view, is terror offenders facing release who might still pose a danger to the public. I see this as the crystallisation of twin concerns about knife crime and terrorism into a new moral panic which challenges the government’s credibility on the sensitive issue of law and order. They know they are vulnerable here after years of cuts to the criminal justice system and other public services.

How alarming, then, to hear James talking about “one of the more interesting ideas floating around” which is “something based on the sectioning power of the Mental Health Act”. The thinking (such as it is) behind this is that if people want to wage jihad, then they must be mentally unwell and need detaining “indefinitely” in hospital until they can be demonstrated to be safe for release – at which point they have presumably “recovered” from the original (unspecified) mental health problem.

In James’ words “It does provide an answer to the question of how do you keep these people off the streets.” I agree, it does provide an answer to that question, and the answer, clear as daylight, is “Not like that.”

The Royal College has published before on the false promises and real dangers of preventive detention relating to people with mental health problems considered to be at risk of homicide. There is also an excellent Position Statement on Counter-terrorism and psychiatry ( https://www.rcpsych.ac.uk/pdf/PS04_16.pdf ) which reviews the subject in detail.

The short version:

• radical beliefs do not mean that a person is suffering from a mental disorder
• it’s unethical and unlawful to detain people without a mental disorder under the Mental Health Act 1983
• preventive detention is unworkable in any event because you have to lock up large numbers of people to prevent one incident
• you can never prove you prevented anything, but you do have to prove that the people need detaining, lawfully and ethically
• doctors will play no part in detaining people because of their political beliefs
• the whole agenda in mental health services at present is the prevention of “blanket restrictions” and a strong push towards less restrictive practices, reducing bed numbers and supported community care, not locking up large numbers of extra people without any mental health problems.

These problems lie with the government, not The Spectator, and their podcasts remain essential listening for all those interested in what’s going on in the world. Here’s the link. The real discussion starts at about 6.10:

Delusions are a common concern in forensic psychiatry, as one part of the triad of psychosis which includes delusions, hallucinations and thought disorder.

The classical definition of a delusion is “a fixed false belief which persists despite evidence to the contrary and which is not culturally bound.”

The nature of an individual’s delusions varies with the patient and is often related to the cultural background. The broad content of delusions ranges widely.

Technological delusions are common and often involve the belief that a microchip has been implanted in the brain allowing others control of the patient’s actions. This is clearly a relatively modern delusion which has arisen since the development of the microchip.

Religious delusions are still common and often involve the belief that one has been given divine powers or that one has a special connection with the divine. Occasionally these delusions are more specific, with the belief that one is Jesus or another significant religious figure.

In the nineteenth century, these grandiose delusions often involved Napoleon Bonaparte, a major figure of the time.

Delusions of the occult are also relatively common, with beliefs about black magic, curses, spirits, demons and the devil being observed regularly in patients from a range of backgrounds ranging from people with a cultural and religious background centred on modern Western European ideas to patients who look to the Caribbean or Africa for their cultural influences and also seen across patients who follow Islam.

There are also more mundane delusions, such as the belief that an individual or individuals are spreading rumours about a person or, even more non-specific, a general sense that a group of people bear ill will or some sort of non-specific malicious intent.

Delusions range in complexity from the very simple to the very elaborate and this often correlates with the level of intellectual functioning of the patient. Patients with a more complex internal world will often have well-developed systematised delusions which they often elaborate in writing and which can be very complex and wide-ranging. Patients with a lower level of intellectual functioning and a relatively simple internal world will often talk about half formed ideas and suspicions centred on immediate neighbours, the local fish and chip shop, the local council and so on which can be vague, non-specific and half-conceived

It is easy to see that these delusions often bear no relation to reality at all and, indeed, part of the definition of a delusion is that it is a false belief.

People who are less familiar with these aspects of the human psyche are often startled by the fact that there may be a some truth to the delusion.

Delusions often relate to subjects about which the person already has strong beliefs. Religious delusions generally occur in people to whom religion already has significance, whether negative or positive. People with delusions about their neighbours often have pre-existing strong feelings about their neighbours. A patient who believes that their neighbours are poisoning them in order to gain control of their affairs probably has negative feelings about the neighbours before any mental illness or symptoms of psychosis manifest. There may already have been some sort of neighbourly dispute before the delusional ideas arise.

A delusional patient who believes that a relative is persecuting them by means of black magic probably already had a strained relationship with that member of their family before the mental health issues arose and the delusions came along.

When exploring or coming to understand the patient’s thinking, people new to this area, including medical students and lay tribunal members, are often struck by the truth at the heart of what can be a wide-ranging and expansive delusional system.

Even in patients with a long (over 10 years) history of the classic symptoms of schizophrenia including third person auditory hallucinations, disorders of thought possession and passivity phenomena, novices in this area are struck by the realisation that the neighbours who have been supposedly pumping poison gas through the walls, using a super chip to control the patient’s behaviours or controlling their actions through voodoo were at one stage involved in a real dispute of some sort with the patient. This realisation is sometimes seen as casting doubt over the diagnosis or changing the situation fundamentally. The layperson assumes that because there is a tiny morsel of real grievance, the entire wider clinical picture is brought into question.

It is clearly the job of the forensic psychiatrists to provide context and the fact that there was an argument between neighbours 15 years ago or the fact that there is still genuine tension between a son and his mother-in-law does not adequately explain a 15 year history of hallucinations, delusions, thought disorder, personality disintegration and poly-substance misuse which is absolutely characteristic of schizophrenia. In fact, the opposite is true: in someone with specific delusions about an individual or group of people we would actively expect that there might be some pre-existing animosity or difficulty between the patient and the other.

This is the truth at heart of the delusion.

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.

Great to be presenting at the recent Medical Education Day in Nottingham. Insightful lecture from Prof Peter Bartlett with a warning about avoiding complacency when considering human rights.

Pavel Trancik came from the Czech Republic to give an update on the European Forensic Psychiatric Trainees’ (EFPT) Scheme and Natalya Kennedy spoke about inspirational work in Sierra Leone. We have experience of the EFPT with psychiatrists visiting from Paris and Brittany earlier this year, as well as others outside the scheme from Italy, Portugal and Spain.

Sorry to see Dr Neil Nixon moving on from the Director of Medical Education role.

Highlight of the panel session for me was a wide ranging discussion about human rights in forensic mental health care with international comparisons. There was both contrast and agreement between the academic legal view (Prof Bartlett) and the clinical view which I was representing. It is essential that clinicians remain engaged with wider discussions about human rights, nationally and internationally, as the landscape is changing and a new paradigm is emerging, beyond the ECHR and HRA.

My LLM in Legal Aspects of Mental Health Practice gave me a lasting interest in mental health law, with a focus on human rights. It’s not possible to stay as up to date with case law as I would like, but the RadcliffesLeBrasseur Annual Mental Health Conference is the next best thing.

One Great George Street is an ideal venue, the cost of the day is reasonable (do they run it at a loss?) and the quality of the speakers is exemplary. Top QCs in relevant areas give an update on case law – case law they have been instrumental in developing, often in some of the highest Courts in the land.

There is usually an update from the CQC, which featured again this year. This is helpful to address concerns about what the aims and policy drivers of the CQC are right now.

Andrew Parsons is always pragmatic and clearly highly experienced. An update and overview of the NHS 5 Year Forward View and how it dovetails with the Long Term Plan was also welcome.

All in all, a good day, with an insight into the ever-developing case law following Cheshire West. For several years, the developments in case law have related to CTOs and DOLS, which are new areas of law, rather than the well-established Sections relevant to in-patient work, stemming largely from the 1959 Act which formed the basis of the 1983 Act.