Zero tolerance of violence

Behr et al (2005) raise important concerns about the relationship of mental health services with the government's Zero Tolerance Campaign against violence towards National Health Service staff. They argue that the suggested blanket exclusion of those with mental illness from this policy is stigmatising and may appear to condone violence towards staff by patients with mental illness. Clearly this would be a bad thing.

However, I have concerns about further justifications for excluding difficult patients from mental health services, this time under the guise of ‘capacity’. We already have a variety of time-honoured procedures for doing this, such as geography (‘not my catchment area’) and diagnoses (‘personality disorder’ or ‘drug-induced psychosis’). The authors seem to imply that patients either have or do not have capacity, failing to reflect the complexity of the law and the notion of capacity as a phenomenon that varies from situation to situation (in other words, with the gravity of the issue in question) and from time to time. It is not a static property of people, nor is it categorical.

Violent behaviour is often a symptom of mental disorder and may require intervention from mental health services. These individuals already have difficulty accessing services. I would argue that what they need is more not less. Clearly it is not acceptable for mental health professionals to be fearful for their own safety at work, and there need to be appropriate resources and settings in which to safely care for such patients. There is, however, undoubtedly an element of risk in working in such settings, which must be acknowledged and safely managed without being condoned. The criminal law applies equally to psychiatric patients, who should be prosecuted if they break the law, just as any other citizen. Perhaps in the world proposed by Behr et al police officers will be able to refuse to arrest violent people and prison officers refuse to attend to violent prisoners?