Tilt (Reference Tilt2003) defends himself clearly against the criticisms of Drs Exworthy & Gunn (Reference Exworthy and Gunn2003). However, he does not emphasise the extent to which they have misrepresented aspects of the Tilt Report (Reference Tilt, Perry and MartinTilt et al, 2000). Specifically, Exworthy & Gunn state, following their quote from the Report concerning the relationship between security and therapy, ‘one should go further because in high secure hospitals therapy in its widest sense is an integral part of security’. This virtually paraphrases the Report itself: ‘Security is the responsibility of all personnel in a high security hospital and... good security facilitates good therapy and vice versa’ (paragraph 8.2).

There also appears to be a marked absence from this debate of both historical and organisational perspectives. Rapoport (Reference Rapoport1960) suggested, in considering the institutional dynamics of therapeutic institutions, that ‘disturbances were partly a function of cycles of abdication of authority, in the name of permissiveness, followed by authoritarianism to restore order’. The consequences of the report on the Ashworth Hospital inquiry (Reference Blom-Cooper, Brown and DolanBlom-Cooper et al, 1992) (Ashworth at that time being an abusive, authoritarian institution) were clearly thought by Fallon et al (Reference Fallon, Bluglass and Edwards1999) to relate to a breakdown of security (permissiveness), leading to the Tilt Report (which has been perceived by many in secure services as authoritarian).

Perhaps attempting to understand this cycle more, and how it may relate to the complex (and potentially contradictory) tasks facing secure psychiatric services, might reduce the likelihood of yet more scandals, inquiries and reports in the future. Scott (Reference Scott1975) suggested that ‘detaining custodial institutions have two aims, one therapeutic, the other custodial. These can and should be complementary, but there is a tendency for these functions to polarise out and eventually split like a living cell into two separate institutions’. The debate between Exworthy & Gunn and Tilt illustrates the recurring nature of this phenomenon. Perhaps this debate needs to move on to a creative engagement with this process.