‘Forensic’ – yet another form of stigma

I read with interest the recent article by Turner & Salter (Psychiatric Bulletin, January 2008, 32, 2–6) and O’Grady's commentary thereof (Psychiatric Bulletin, January 2008, 32, 6–7) on the borderline between forensic and general adult psychiatry, and I have to disagree with authors. I think it would be more healthy to concentrate on the actual patient rather than various artificial classifications that have been cooked up over the past years.

Prior to returning to forensic psychiatry I was mainly involved with the seriously mentally ill and their treatment. I have noticed that in fact the patients have changed very little, it is just the surroundings and legal paraphernalia, etc. that have. We still see people with severe psychosis who have not responded to treatment for a variety of reasons, some of them having personality disorder alongside psychotic illnesses and some with personality disorder per se. Our role as psychiatrists with such patients is key to achieving the maximum stabilisation to enable them to live as normal a life as possible within a setting that is suitable for them. I regard the rest of the paraphernalia and surrounding status as largely irrelevant, from a purely psychiatric point of view.

It would appear that there are many people who seek to interfere with the treatment and care of these patients, in particular members of the legal profession who have on occasion given me detailed instructions on what medical treatment to deliver to their client. Clearly they are no more qualified in that, than I am in giving them legal advice for my patients. It would seem that the cause of the increased number of ‘forensic’ patients is merely due to a breakdown in the quality of care given to these people in the community. I think the current political idea that one system fits all has been an abject failure, as indeed are all generalised solutions to the needs of individual patients. Obviously most people with severe mental illness will be able to live in some capacity in the community without any problems with violence or suicide, but there still remains a significant number who will never be able to do this, however much politicians seek to deny this. I have met many of such people and I can recognise their mental pain as they struggle to come to terms with a rigid system into which they will never fit.

In addition to these problems, of course, millions of pounds have been spent to enable us to reach this situation and it is frightening to think where this money might have been spent more usefully.