ABSTRACT
Over the past decade, the practice and the image of psychiatry in the inner city has been dominated by a succession of incidents involving black patients, generally young men diagnosed with schizophrenia, who are characterized as the perpetrators of homicidal violence. Christopher Clunis, a young black man with schizophrenia who killed, without provocation and apparently at random, a complete stranger, is one of a number of young psychotic men whose violence has led to the hasty enactment of legislative and administrative measures (notably the Supervision Register and Supervised Discharge Order) aimed at preventing severely mentally ill people from harming members of the public. Under the new Care Programme Approach and Section 117 of the last Mental Health Act, detailed arrangements have to be made to supervise the patient’s living arrangements and to ensure access to training and work-a daunting task when unemployment among young Afro-Caribbeans is three times as high as for whites of the same age. There is a heavy emphasis on the role and on the regular administration of antipsychotic medication. When patients who have a diagnosis of schizophrenia and a history of severely disturbed behaviour refuse to take their medication (‘failure to comply’), the local mental health team are expected to take action to ‘prevent another Clunis’. Prescribed measures include increased
surveillance to detect early warning signs of relapse or of the increased use of illicit drugs or alcohol. If the patient’s condition is deemed to be deteriorating then urgent readmission to hospital, usually on a compulsory basis, is regarded as mandatory and failure to implement the return of the patient to hospital is condemned as medically negligent. The typical inner-city psychiatry ward will admit two or three such patients each week. A drama of mutual suspicion, lack of trust, resentment and fear is repeatedly played out. Almost invariably the patient, often black in an institution where senior staff are white, does not share the perspective of the mental health workers. Because of his (and it is usually his) lack of ‘insight’ (i.e., a reluctance to share the professionals’ view of his emotions, thoughts and actions), he not only refuses to take his antipsychotic medication but, logically, refuses to come into hospital voluntarily where he knows that the medication will be administered forcibly. He does not attribute any aspect of his inner life to mental illness; he finds the side effects of medication intolerable (impotence, sluggishness, shakiness, restlessness and obesity) and he feels degraded by the fortnightly injection into his buttocks.
