Journal of Clinical Nursing 1993; 2: 61-62

Editorial Custodial community care or therapeutic treatment?

The issue of community treatment orders for people with chronic mental-healthproblems in England is being widely discussed due to a young man, who hadsuffered from schizophrenia for nearly fO years, throwing himself into the lions'cage at London Zoo. As a result of his action, he was mauled by the lions andreceived medical treatment in intensive care. His father has since contrasted the

, extent of the community mental-health care offered to his son following hisdischarge from psychiatric hospital, with the extremely expensive and highly

• N, : skilled medical and nursing care delivered to him after the event at London Zoo.Several mental-health pressure groups have supported the father's comments,using the illustrative case to draw society's attention to the inequalities between

, r ; -,, resources made available for high-tech care and those provided to assist people,,» V. ^ with chronic mental illness in maintaining standards of living within community

settings.Two camps have arisen—one that supports the introduction of community

, ,.:« i.'i treatment orders; and one that has rejected the idea on grounds of human rights.It is difficult to believe that either camp has considered all the issues involved.

; While it is possible to introduce a law concerning community treatment, puttinginto operation the content of that law would be much more complex. Mostclinical nurses involved in psychiatric settings, will have been faced with the

. : ,.: situation of having to medicate a patient forcibly against their will, usually in an, ;i :•. in-patient setting although occasionally at home. This is no easy task and may

require physical restraint. Yet, whenever possible patients should be encouragedto comply with treatment through persuasion, not force. A prerequisite to anynurse persuading a patient to take medication, albeit reluctantly, is a trustingrelationship between two individuals. Such relationships can only be built over

. • ••' i , time and require highly skilled nurses who are both able to monitor individual: patient states and arrange suitable intervention to prevent severe deterioration in

their mental health. It seems, therefore, that the issue is not one of whether or not. I f s I community treatment orders are desirable, but rather are sufficient resources

, '. • " available to provide supportive nursing care for people with mental illness in• ._ •:•• I community settings.'

\.\ ; •. If it is accepted that psychotic diseases such as schizophrenia and manicr. ,,-..-• . depression have a biochemical cause, any civilized society has a responsibility to

provide adequate health-care services, in both hospital and community settings,for people who are diagnosed as suffering from these illnesses. By providing

, ivy •.^\.•^ry sufficient community staff to support people with mental-health problemsadequately, the need to resort to the law in order to treat individuals should beextremely rare. There is some evidence from research conducted in London

; • I 1 ... ! involving a team assessment of psychiatric services that people with psychoticJ , • : ', illnesses, given sufficient support in community homes, are able to cope and that

breakdowns of mental health are significantly reduced. It is worth noting,however, that even in extremely well-supported community homes, residents

;. , have been re-admitted to hospital to stabilize medication (Tomlinson, 1991)..' i Perhaps the best way forward would be to ensure that all people who are

diagnosed as having severe psychotic illnesses, are followed up in the communityon a regular basis by skilled community nurses in order that they can receive

61

62 Editorial

optimal care in the community and, where vital, be admitted to hospital swiftly.No-one would wish to return to a situation where patients are incarcerated in

hospital, but neither can we get to the point where community care becomes-in'y(;jUi-r\t >r custodial care rather than involving therapeutic treatment. Clearly, there is a

place for hospitals to be used as an asylum in the positive sense of the word, for• • ! " , . ' V;• ,i ,(rj.,',.'| T people who are suffering from an acute psychotic episode to withdraw from

society and be treated with dignity and privacy. Community treatment orderscould lead to a situation where the only option open to such people is to be treated

,f' IJ..!MI;III i.r/ -ifi r)ii forcibly in front of relatives and friends—surely an affront to human rights.

Editor • ™ " - " — • — — • '- ' • . MARYWATKINSBeeches, Crapstone, January 199.1Yelverton

tf: Iff-'' ; :i!\) r ; !! :! ; m ; , ! ' D e v o n P L 2 0 7 P W , U K : , : ! . v ; n b O i i , ! . -

-:^<-<b f;-:,!. •: R e f e r e n c e

l l.i .'l/<-,i;:' • Tomlinson D. (1991) Utopia, Community Care and the Retreat from the Asylums.University Press, Milton Kcyncs.

\ U i - , ' ! ' ] r r : i i ; i ' J

1 : r ; i : i > : i ' . , " . ' ; i . | : ' ; • . ] , > ' I t . i l

. . - ; ( i ) ' ! : : i : ( i l I ' r j i ' i ' f ] : i \ \ '

: " : f - ' ' l ; ! M " J . .•: . r l u : . - ' • ; , • : V ' J L ; ; I : - i i ^ I I ; , ; s ; '. r • , i - i \ . j i ,•: > '

i.1 ' , • ; . ' [ ; : ; j - ^ r i j ' . ' , , n - : • ! , , 1 i ' v ; U . ^ i i P - j t l v ; : : : ; ^ ; . i ) , i O : • ' - i ' ! , ! ,

: ; ( . • • , r i ; y £ . j i , r;;,

. i i .id i . i i u i j / ' lnhfii^.' 'i !••

frt