The Poison Chalice – Systematic Failures Within the New Zealand Mental Health System

A Presentation To the Annual Sensible Sentencing Trust Victims Conference
Napier, September 2012
by Graham Moyle, Mental Health Spokesman

On Friday the 11th of May 2007 my older brother Colin returned to his recently acquired flat in the Auckland suburb of Sandringham. He had been to the local dairy where he had bought a stamp and posted a mothers day card which duly arrived at my parents house on the following Monday. This was to be the last task Colin would complete. As he opened his front door he was repelled by the deep burning of his flesh as a jug of boiling water was thrown into his face. Reeling from the agonising pain he stumbled from the doorway onto the front lawn. Colin was then beaten relentlessly by his attacker using a spade, until, weakened by the ferocity of the impact, the handle of the spade broke. This premeditated, frenzied assault did not however end there. Taking a can of lawn mower petrol, stolen earlier from a neighbouring property, Colin’s assailant then doused my brother’s lifeless body with the fuel and set him alight.

I, like you all, joined the Sensible Sentencing Trust the hard way. Mother’s day in our family is no longer a day of celebration, it is a day of immense pain and emotion and a sad reminder of how precious and sometimes short life can be.

Colin’s murderer, Matthew Ahlquist, had been the recipient of mental health care by the Auckland District Health Board for the previous 10 years. In the months leading up to Colin’s death Ahlquist had hospitalised his father, having bashed him about the head with a can of fruit, threatened to kill 3 of his psychiatrists and assaulted a member of the public. On his final admission to psychiatric care Ahlquist told the doctors he wanted to kill someone. Without Ahlquist’s parent’s knowledge and against their wishes Dr Thom Rudegeair discharged his patient from the Clinic to no fixed abode, without any support or follow up care or a relapse prevention plan. Ahlquist was handed the opportunity to carry out the murder he had warned would take place, the only unpredictable facet of his plan was who would be his eventual victim. Ahlquist was found not guilty by reason of insanity for the cold blooded, calculated, premeditated murder of Colin Moyle. He carries no conviction for his offending!

Matthew Ahlquist is a patient, not an offender, a client not a prisoner, he is to be treated for his illness, not punished for his actions. His victim has been forgotten and all attention is focused on curing Ahlquist from an incurable disease so he can be placed back into the community as soon as possible. Proof of the expediency with which his psychiatrists expect Ahlquist to be out amongst us came less than 3 years after Colin’s murder when we were informed that the Director of Mental Health, David Chaplow, had granted Ahlquist unescorted leave from his treatment facility. This means that when he has earned the trust of his doctors he can spend up to 6 nights a week living, unsupervised in the community.

My brief then for this presentation was to give an update of mental health system failures as I see it and to offer some possible solutions.

The following areas of concern,if corrected, would in my view prevent many tragedies, not only with regards to murder and assaults, but also stemming the tide of suicide which is permeating our country and something the Chief Coroner has been very vocal about.

Pre-Offending Issues

FAILURE TO LISTEN TO FAMILIES;
For years the families of potentially dangerous people suffering from serious mental illness have begged and pleaded with doctors to do something to stop their sick relatives from killing someone, but for years their concerns have been ignored with tragic consequences.

GATEKEEPING;
Due to the lack of beds for the mentally ill, an unwritten policy of gate keeping exists to reduce admissions. Patients with serious mental illnesses are routinely reclassified or misdiagnosed as having personality disorders to avoid having to admit them into a psychiatric facility. Many of these people therefore become the problem of the criminal justice system.

LACK OF BEDS;
A chronic shortage of psychiatric beds has put pressure on hospitals to shunt patients out of hospital and onto the streets. Fewer beds are perceived as being better, clinically and fiscally, however, too few beds mean you shorten patient stays to a point where they are discharged without adequate diagnosis or treatment. Since the wholesale closure of psychiatric hospitals throughout the 70s, 80s and 90s, psychiatric inpatient beds have dwindled from approximately 10,000 to a paltry 600.

COMMUNITY CARE;
Nice philosophy but simply unworkable due to financial constraints, resourcing and the sheer numbers of seriously ill patients living in the community requiring care and supervision. Estimates would suggest patients may receive one visit from a health professional per week, hardly enough to monitor medication compliance, behaviour or the use of alcohol or illicit drugs. Often these individuals live in substandard accommodation, if they have accommodation at all, sometimes living amidst prisoners on parole, alcoholics and drug users. Many are also ill equipped to take care of themselves or to manage money.

RELAPSE PREVENTION PLANS;
Relapse plans are supposed to be put in place prior to discharging mental health patients. These are designed by the clinician, the patient and the patients support network and family. Sadly, however these are not always robust or effective and not all patients receive an adequate relapse plan upon discharge. An example of this is when Matthew Ahlquist was discharged he was released to the street, he had no address, or support mechanisms in place to monitor him in the community. He was transient and slept rough.

HOMELESSNESS;
Due to the lack of medium to long term inpatient beds and the ‘community care’ philosophy, homelessness amongst the mentally ill is a huge problem and is plainly evident in the CBD of any major town or city. As previously mentioned Matthew Ahlquist was discharged to the street, his parents weren’t even advised that he’d been discharged; he had no address, support or relapse plan in place to monitor him in the community, as I mentioned he was transient and slept rough.

200 hundred years ago the mentally ill survived outdoors and in squalor, today, in an enlightened society, due to deinstitutionalisation and ‘community care’, many of our mentally ill still exist in the open air; parks, alleys, vacant lots, shop doorways, under bridges and on our footpaths, a return to the middle ages where the mentally ill roamed the streets and children threw rocks at them. The freedom to be insane is an illusion, a falsity, inflicted on those who cannot think for themselves.

MEDICATION NON-COMPLIANCE, DRUGS AND ALCOHOL ABUSE;
There are individuals who refuse treatment because due to the nature of their illness they believe there is nothing wrong with them. The part of the brain which allows a normal person to check beliefs against reality is damaged and the only way they will ever be treated is involuntary. Many anti- psychotic medications cause unpleasant side effects so patients prefer to self-medicate using alcohol or illicit drugs which in turn worsens their symptoms.

UNPREDICTABILITY OF DANGEROUSNESS;
Deaths, homicides and suicides caused due to acute mental illness are as preventable as road accidents. Psychiatrists need to improve how they assess the risk of violent behaviour among people with serious mental illness.

Violent behaviour undermines confidence in the mental health system and feeds public perception of mentally ill people. Despite the harm caused by violent behaviour in the mentally ill, their families and public perception, it appears psychiatrists are not very effective or confident in assessing the risks. Inquiries have found a failure by clinicians to take the reports of others seriously, failure to use compulsory treatment, a tendency to be cross sectional and not take past history on board and a failure to share information. This admission from Dr Sandy Simpson, former head of the Mason Clinic.

These risk assessments are the most controversial aspect of mental health legislation. Our legal system is based upon the mandate that incarceration of individuals occurs only after a crime has been committed, not before. However, in the mental health context, people assessed as high risk can be detained on the basis that they may commit a crime in the future, however as Dr Simpson admits, this is done poorly if at all. Matthew Ahlquist made 4 threats to kill and none were taken seriously.

Post Offending

POLICE CALLOUTS TO MENTAL PATIENTS;
In the last 10 years Police Callouts to incidents involving a mentally disturbed offender have risen by a staggering 56% from 6,860 in 2002 to 10,734 in 2011.

PERCENTAGE OF MURDERS BY THE MENTALLY ILL;
8.7% of all murders are carried out by an offender with mental illness. Psychiatrists believe this is acceptable and use words like “only” and “insignificant” when discussing this number. 9 victims out of every 100 are very significant considering most of them, like Colin, could have been prevented.

REPORTING OF HOMICIDES TO THE DIRECTOR OF MENTAL HEALTH;
District Health Boards are required to report any suicide to the Director of Mental Health by a patient under its care within 14 days of the death. No such requirement is necessary if a homicide is carried out by a mental health patient under District Health Board care.

NOT FIT TO PLEA;
A growing number of offenders don’t complete their journey through the courts as they have been found too mentally unwell to enter a plea to the charges against them. They are therefore remanded to psychiatric care until such time as their mental health improves and they understand the nature of their offending.

This however is not always the case. Earlier this year, a defence team and judge allowed an offender in a high profile case that had numerous female victims, to submit an ‘unfit to plea’ defence as he suffered from mild dementia. Subsequently the offender walked free to live at his own residence without a conviction. It is my contention that if you are unfit to plea, then you are unfit to be free!

THE TEST FOR INSANITY;
Insanity is a legal term not a medical one. The use of this defence and the basis of the legislation has been in use and basically unchanged since the 1840s, with no regard to advances in psychiatry or medicine.

The guts of the whole defence is based on whether the offender knew that what he was doing was not morally wrong at the time of the offence. This is not scientific, it is opinioned-based, at worse – guess work. Psychiatrists are routinely called to give independent expert testimony on the mental state of a defendant at the time of an offence, months after the crime has occurred.

For instance, Dr Phil Brinded whose testimony was used as evidence at Ahlquist’s trial never spoke to Ahlquist until 15 months after Colin’s murder yet was able to conclude that Ahlquist didn’t know that murdering Colin was morally wrong. Furthermore, Brinded had access to reports from the defence psychiatrists prior to writing his own, which in my view could have influenced his independent expert testimony.

Morals are subjective depending on the individual. An al Qaeda suicide bomber believes he is in the thrust of a holy war and in his view is morally obligated to rid the earth of infidels. His morals are clearly at odds with the rest of the western world.

THE INSANITY DEFENCE;
In the 10 years from 2000 to 2010 the successful use of the insanity defence has risen by 300%. The ‘community care’ philosophy is based on the model that patients are better off living in the community amongst ‘normal’ people, so they themselves feel ‘normal’, however when they offend the Justice System wants to treat them differently from the rest of the community and diminish their responsibility by blaming their offending on their illness and giving them the opportunity to plead not guilty due their illness. Once found not guilty by reason of insanity they carry no conviction and do not need to declare their offending when applying for employment where Police vetting is a prerequisite.

Once acquitted due to insanity, the offender is then treated as a patient so no definitive term of treatment is imposed. At sentencing, Judges often try and reassure families and victims that these ‘special patients’ will probably spend more time in a psychiatric hospital than in prison had they been found guilty. This is naïve and is completely false, as I mentioned earlier Matthew Ahlquist was granted unescorted leave only 3 years after murdering Colin. This is the first step in preparing these patients for release. Stephen Anderson was released after 12 years for the murder of 6 people in Raurimu in 1999. He thankfully has been recalled due to a deterioration of his mental health. As already discussed these offenders are not treated as criminals, they are classed as ‘patients’ and the focus is on their treatment, not public safety.

PRISONS : THE NEW MENTAL HEALTH INSTITUTIONS;
It is no coincidence that when the wholesale closure of psychiatric hospitals began in the 70s 80s and 90s the prison muster in turn, increased, a worldwide trend that emerged when the ‘community care’ philosophy was introduced.

A report published by the Auditor General in 2008 stated….

  • An estimated 15% of all prison inmates should be receiving specialist mental health care for psychotic illnesses including schizophrenia, bipolar mood disorder and major depression
  • A further 10% of the prison population could experience mental illness requiring specialist care.
  • Almost one third of the prison population could experience mild to moderate mental health problems.
  • Prisoners are 3 times more likely to require access to specialist mental health services than the general population.
  • The prevalence of schizophrenia in the community is 0.4% but is 6% in prisons.
  • The prevalence of bipolar disorder in the community is 0.7% but is 2% in prisons.
  • The prevalence of major depression in the community is 13% but is 21% in prisons.

These figures go a long way to support the notion that although we have closed most of our psychiatric institutions, they still exist albeit under a different name. With small numbers of psychiatric beds on its books, this country looks like it has mental health care under control, in reality however that is an illusion and prisons are paying the price for that deception.

PRISON TRANSFER TO PSYCHIATRIC HOSPITAL;
Issues have come to light recently where convicted murderers have been transferred to psychiatric hospitals due to alleged deterioration in their mental health. Confusion exists between the Department of Corrections, the Ministry of Health and the Parole Board over which agency has custody of the offender which is of real concern, as the Ministry of Health is concerned with treating the offender for their illness, rather than punishing them for their crimes, which has the potential of early release under the guise of rehabilitation.

DESENSITISED CLINICIANS;
Some psychiatric staff have become so used to dealing with high risk patients that they fail to recognise the warning signs that they may turn violent. Many psychiatric staff identify so completely with the perspective of their patients they often dismiss their potential risk.

ACCOUNTABILITY;
There is no form of accountability for psychiatrists who, despite overwhelming evidence as to a patient’s dangerousness, release them into the community. Complaints to the Health and Disability Commissioner of this nature may result in a period of supervision being imposed on the psychiatrist involved, but there is no evidence of any psychiatrist being disciplined or struck off for patient mismanagement of this kind, in fact a psychiatrist needs three complaints against him before the HDC will even divulge their name.

Solutions

Where do you begin?

If I could pick two to start the ball rolling, and I believe they are probably the easiest and cheapest to remedy, they would have to be changing the insanity defence and secondly, making psychiatrists accountable for inadequate care of potentially dangerous mentally ill patients.

THE INSANITY DEFENCE;

A restructure, of the insanity defence is, in my view required. My vision of this would look something like this.

The defendant is processed through the courts as normal, regardless of any perceived or real mental illness. The only plea available to the defendant would be guilty or not guilty.

The trial would proceed as normal with a jury to determine guilt.

Once guilt has been established, the jury is dismissed and then the mental illness aspect of the offending can be introduced prior to sentencing.

Once proven that the defendant’s mental health had a significant part to play in the offence, the Judges could then hand down an alternative verdict of Guilty, But Mentally Ill, which would carry a conviction, and a definitive length of treatment.

The offender would then be admitted to a secure Forensic Mental Health Facility.

Should the offender ‘recover’ from their ‘illness’, rather than consider them for unescorted leave, which is now the case, the patient should be reclassified and sent to prison for the remainder of their ‘treatment period’, where they can continue to receive treatment if necessary and be kept under supervision. Upon release they would be required to comply with medication, avoid drugs and alcohol or risk being recalled.

ACCOUNTABILITY;

Like the Christies Law campaign seeking that Judges be performance reviewed I would like to see psychiatrists come under scrutiny, disciplined and prevented from practicing when they are involved in decisions that have fatal results such as suicide or homicide.

I would also recommend an obligation that the Director of Mental Health be formally advised of any homicide perpetrated by a patient receiving treatment through a District Health Board as is the case with suicide.

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