Prosecuting violent in-patients: the importance of staff attitudes

The editorial by Wilson et al [1][1] highlights important dilemmas faced by mental health professionals in relation to reporting violence perpetrated by mentally disordered patients. We welcome the proposals made by the authors, but unless there is a significant change in staff attitudes to


Prosecuting violent in-patients: the importance of staff attitudes
The editorial by Wilson et al 1 highlights important dilemmas faced by mental health professionals in relation to reporting violence perpetrated by mentally disordered patients. We welcome the proposals made by the authors, but unless there is a significant change in staff attitudes to reporting non-trivial violence perpetrated by psychiatric patients, progress in this area is unlikely to occur.
Our observation is underpinned by the results of two surveys which we carried out in a medium secure unit in Middlesbrough in 2006 and 2008. There were 80 incidents of assaults on staff by in-patients, the majority of incidents having been perpetrated by a minority (2006: 43 assaults, n = 10/100; 2008: 37 assaults, n = 14/100). Despite being a medium secure unit, the majority of assaults were perpetrated by patients detained under Part 2 of the Mental Health Act and by female patients. Only 10 incidents (12.5%) were reported to the police, despite 70% of nursing staff being aware of the memorandum of understanding (www.cp3.gov.uk/publications/agencies/mounhs.html). We explored the attitudes of nursing staff using self-report attitude questionnaires (each of the 13 attitude statements measured on a 5-point Likert scale) to identify enablers or barriers to reporting incidents.
In both surveys, approximately a third of respondents feared that reporting incidents would result in a breakdown of therapeutic relationships with patients and a half feared reprisal from patients following reporting. In 2006, half of respondents considered being assaulted as an 'occupational hazard', but encouragingly this attitude was reported only by a quarter of respondents in 2008. Although 84% of nursing staff understood that they had a 'right to report', a fifth believed that reporting incidents was a bureaucratic exercise without any benefits and for 60% the required reporting forms and procedures were difficult to complete. Staff were more likely to report incidents perpetrated by patients with personality disorder than those with other mental illness. About 20% of staff stated that they would only report incidents which resulted in physical injury. Only 40% believed that reporting incidents would strongly deter patients from re-assaulting. Some of these free-text comments capture the ambivalence in this area: 'I came to the nursing profession to help patients, not to be a punch bag'; 'I would report only if the assaults were due to ''badness'' not ''madness'' '; 'Disillusioned towards the police dealing with incidents'; 'Waste of time'; 'Zero tolerance should mean zero tolerance'.
In summary, whereas we acknowledge the value in developing robust policies, procedures and systems to address this important issue, significant progress in this area is unlikely to occur unless considerable efforts are made to shift attitudes of mental health professionals. Campaigns and systems to report and reduce violence are akin to taking a horse to water. Making a change will require a change of attitudes in relation to reporting violent incidents to the police. We propose that this can be achieved by discussing patient assaults in staff induction training, appraisal, supervision sessions and trust audits.

Discrimination between psychotropic and non-psychotropic treatment by patients
Perecherla & Macdonald 1 state that they found no evidence that patients discriminated between psychotropic and nonpsychotropic treatment. Elsewhere, a lack of concordance with psychotropic medication has been reported to be as high as 75% over the course of a year. 2 Although this may be on a par with adherence to non-psychotropic medications, there were significant factors which were not taken into consideration in Perecherla & Macdonald's study.
Only patients who could communicate in English were included. This may have excluded patients from ethnic minority groups and other backgrounds, thereby ignoring their cultural and religious beliefs regarding medication. This surely must reduce the relevance of the results to populations with a significant proportion of ethnic groups. Further, the authors were unable to ascertain the duration of treatment in participants. This is an important factor as adherence improves with development of insight. 3 The opposite is true of acute relapse.
In addition, it is not clear whether the sample was drawn from acute or long-stay wards and whether it consisted of patients who were stable on psychotropic medication and had insight or were acutely unwell. It is quite possible that most of the sample were patients who were stabilised on a drug regime, had insight and knew the purpose of their psychotropic medication. However, this may not be the case in acute episodes of care where the patient often lacks insight and questions the need to continue psychotropic medications. The authors state that in case of participants on more than two psychotropics, the 'longest-term treatment option' was selected. We fail to understand how this was established if duration of treatment was unknown. In the example given of a patient with bipolar disorder, the mood stabiliser was selected rather than the antipsychotic as the primary treatment; this was based on the assumption that mood stabilisers had been used first. However, it is well known that many patients are treated with antipsychotics as first-line medication. It is quite COLUMNS Correspondence