Ask a different question.

This was originally posted on the University of Liverpool website on 28th June 2013; http://news.liv.ac.uk/2013/06/28/the-liverpool-view-ian-brady-ask-a-different-question/

Today, a Mental Health Tribunal has announced its decision that Ian Brady should remain a patient of Ashworth Hospital.

So what does all this mean about Mental Health Tribunals in cases such as these? First, in my opinion, the central (and hugely important) issues for a Tribunal should be to answer two key questions: what sort of care does a person require and, assuming they disagree, are they psychologically capable of making that decision?

Issues of mental health and psychological capacity are matters for deciding on the practicalities of where (prison or secure hospital) the person should reside. Criminologists, psychologists, sociologists and doctors must try to understand why people do what they do, but the concept of “illness” is unhelpful.  Questions of guilt and the reasons for the commission of crimes are matters for criminal courts, not Mental Health Tribunals.

In my opinion, this case is a good example of how we need to re-think fundamental issues about mental health and human behaviour. I do think – and it’s important to stress this – that everybody has a right to be cared for in the manner most appropriate to their needs.

The staff in psychiatric hospitals have distinctive and hugely valuable skills needed to help people who are suicidal, who self-harm, hear voices or are terrified by paranoid delusions. We are all, including those convicted of criminal activity, entitled to appropriate, high-quality care.

Of course, we might all agree that a hospital is the right place, but the individual concerned may well disagree. This is, in essence, the substance of many Tribunal decisions. I do not believe that this issue is best addressed by asking if a person is “ill”.

Instead we need to consider two key questions; a) is it clear that hospital care is the right course of action?, b) in cases where the individual disagrees, are they in a position to make a decision for themselves? If a person is able to make a rational decision to refuse hospital care, in my opinion, that decision should stand. But that decision shouldn’t be based on the question of “illness”. It should be based on the person’s capacity to make a decision for themselves.

So, in my opinion, tribunals should be focused squarely on the needs of the individual and their capacity to make decisions, for themselves, about the care being offered.

Public discussion of Ian Brady’s case, because of his notoriety and the unique experience of a public Mental Health Tribunal, has also focused on issues of madness and responsibility for crimes. And here, again, the issue of illness, in my opinion, needs to be re-thought. We do need to understand and explain why people behave in such ways, but I don’t think the language of “illness” helps here either.

Although I think it’s extremely unlikely, we do need to think about whether some biological abnormality might be a factor in crimes of this nature. But if that were to be the case, it’s close to impossible to see how such a finding would relate to the diagnostic morass that all observers find themselves in (and always have).

For any diagnosis, the vast majority with such a diagnosis would never commit crimes such as Brady’s, and the vast majority of homicides are associated with no mental health diagnosis, let alone a specific one. There are absolutely reasons why those convicted of serious crime do what they do – and those reasons are psychological, social and, perhaps even biological.

But it cannot be said that “they did what they did because they are sick” is any kind of satisfactory answer.