Risky door business

Queensland, Australia takes a step backward – Springborg spring-loads the doors slamming shut human rights

I write this post, ironically with an ear to the Johannesburg memorial service for Nelson Mandela screening on my TV. Here I sit reflecting on the life of a remarkable man who fought for the human rights of some of the most vulnerable people in the world, and I wonder, how could people have come to a logical conclusion in years gone by that it could be possible to consider denying the freedom of people as an ‘OK’ human behaviour? How could it be that liberty could be denied to people based on something as illogical as the colour of one’s skin….It defies all reason…… but still it happened…. The fight to freedom was a costly one. South Africa continues to work towards peace and recovery… triggered by the leadership of Nelson Mandela. There is hope…

And then I read of plans afoot for Queensland mental health to deny the freedom of vulnerable people who experience mental health problems and who choose to seek help in the voluntary public mental health system by taking steps to lock people in hospital wards to detain them because of a (misplaced) perception of risk associated with mental illness. And I wonder…. How could people (powerful leaders) have come to a logical conclusion these days, this week … that it anywhere near reasonable to even contemplate denying the freedom of people as an ‘OK’ human behavior based on a suspicion of risk. I wonder who should be scared of who?…. I wonder how far have we come? ….or not…….

And then I see that the some parts of the print media have had a field day scare mongering and doing their utmost to fuel stigma… and I wonder how the editor of the Courier Mail could have come to a conclusion that this article is “OK” – it isn’t. The assumptions about mental illness and risk or danger are erroneous and defame those clever , people who show a great deal of personal health and wellbeing safety by ensuring that they seek help for mental health problems when they need it – in a voluntary capacity. And for this responsible and safe healthy behavior effort….. people will now have the doors locked behind them, detained…..under a suspicion of risk…… and I wonder – why would a person seek mental health help if they know that reaching out for support with result in a deprivation of theirliberty? How can that be ‘OK’ – it is not.

In NSW, behind custodial doors most people have one or more mental health problems…

The NSW Law Reform Commission undertook a general review of criminal law and procedures that are applied to people with cognitive and mental health impairment in NSW, and they reported that in NSW of all the young people (less than 18 years of age) detained in custody in NSW, 87% have at least one mental health problem and 73% have two or more mental health diagnoses (New South Wales Law Reform Commission., 2012). Young people with mental illness are over-represented in the criminal justice system compared with the wider population, where 22% of the general population have a diagnosable mental health problem, while the total prisoner population in NSW experience mental health problems at a rate triple that of the general population (New South Wales Law Reform Commission., 2012).

Policing and health service dealing with unwilling young people affected by mental health issues

Police have powers to detain a person who they believe to be mentally ill or mentally disordered, under the Mental Health Act 2007 (NSW), and they can formally request that the person be admitted to a involuntary mental health facility. This mode of request for admission makes up 23% of all police requests for admissions to mental health facilities, however 26% of those police requests do not meet medical criteria for involuntary admission to a mental health unit (New South Wales Law Reform Commission., 2012). This leaves a substantial number of people who may have a mental health problem, but do not meet the extreme criteria for involuntary treatment in a compromised position of not being able to access mental health help when it is needed, and at risk of reoffending and further complicating their offending track record (New South Wales Law Reform Commission., 2012).

Inadequacy of clinical decision-making based on risk assessment

Collaboration between the State governed Police, Health and Ambulance services in regard to supporting people with a mental health problem to access appropriate care is ideal and fits neatly with the ideals of a ‘no wrong door‘ to seek mental health help which are aspired to by State and National Mental Health Commissions. However, there are significant limitations within clinical decision making capabilities which need to be considered. In particular, no clinical risk assessment tools exist with adequate specificity, sensitivity and accuracy to predict harm to self or others, for example violence, by people affected by mental health disorder or illness (Ryan, Nielssen, Paton, & Large, 2010). It is not possible to accurately conclude that commonly used current clinical assessment of risk investigations will be sensitive enough to predict which clients will need higher levels of resource-heavy interventions and restrictive care, and which people will require fewer and less expensive clinical resources and less restrictive care to achieve the desired safety outcomes (Ryan, et al., 2010).

Ryan et al (2010) reviewed the efficacy of the most commonly used risk assessment instrument, that is, the Macarthur Violence Risk Assessment, which is regarded widely as a valid instrument for use in the prediction of violence amongst people who are acutely mentally ill (Monahan, Steadman, & Robbins, 2005). Ryan, et al., (2010) re-examined the data in the original study and found that the level of sensitively for accurate prediction was ambiguous and that it had very poor sensitivity in regard to accurately detecting risk related to future violence. In fact, the sensitivity of the instrument produced 9% incidence of false-negative cases, where people were categorised as being low-risk and went on to commit violent acts to themselves or others in the 20 weeks immediately following the assessment (Ryan, et al., 2010). Thus, 9% of mentally ill people who were considered to be ‘low-risk’ for harm to themselves or others were in fact ‘high-risk’. These people will slip through gaps in service streams of all types despite having been provided with a clinical mental health risk assessment, because to date no current instruments are available to sufficiently and accurately detect risk. However they are in common use despite this paradox and despite an insufficient body of evidence to underpin the continued use of risk assessment to inform clinical decision making (Ryan, et al., 2010).

Health services from an actuarial perspective are adverse to risk events and wish to be seen to be doing everything possible to reduce the risk of harm to people. The risk of homicide by a person with schizophrenia is 1 in 10,000 (Ryan et al., 2010). However Ryan, et al., (2010) have been able to demonstrate, that based on the fidelity of the most common risk assessment tool, if a usual risk assessment was conducted on every person with schizophrenia, that annually 4117 people would be detained for up to a year in mental health bed-based facilities because they would statistically achieve a ‘high-risk’ categorisation. Thus, in order to prevent one person committing a homicide, using the Macarthur Violence Risk Assessment scale, 4116 people would have to be detained perhaps needlessly (Ryan, et al., 2010). However, of those people assessed as low-risk, 1 in every 22,421 people would in fact go on to commit homicide (Ryan, et al., 2010). The health resources and costs absorbed by keeping false-negative cases in hospital detract from the finances and recourses available to provide care to the low-risk cases. Some of the low-risk cases in fact require higher levels of care, but are not deemed eligible because they did not meet the ‘high risk’ categorisation at assessment (Ryan, et al., 2010). The dispersal of health resources could be better allocated across broader mental health criterion, and improve support for the mental health care of more people if the use of clinical risk assessment was abandoned as having any role in the clinical decision making process (Ryan, et al., 2010).

Risk is the wrong reason to lock a door…

A couple of links that highlight better practice about open doors, open and transparent rapport with mental health clients and reasons keep the doors unlocked….



think about joining the campaign to keep voluntary mental health care an open door policy – sign a campaign here



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