Patients who are dangerous at baseline
Imagine this man living on the same street as you and your teenage daughter.
This tall, young, powerful man was admitted onto our secure ward only after he had put half the male staff on his acute ward off sick from his violence. NB the pathetic consultant psychiatrist had ignored this until the patient attacked him. Poor lamb had his glasses broken before nursing staff rescued him. On secure wards back then, there was a low bar for restraining such patients. They had to go a bit further that just look aggressively at staff, but not much more. Excepting patients who actually were genuinely mad and disinhibited, PDs usually quickly learned to wind their necks in.
If this wretch had ever suffered any kind of mental illness then I never saw it. It’s possible he’d received sufficient medication on the acute ward before we got him but I don’t think so. To me he was a narcissistic PD with a strong sense of entitlement. He used to talk a lot about getting himself a 15 year old girlfriend when he got out, a virgin with no experience of men. He’d train her to ‘meet his needs’. I could make no dent in his sense of entitlement to have whatever he wanted, no appeal to the rights of others, to consensual relationships. When his section ran out, we agonised over letting him go but he was not sectionable. Nowhere near it.
Here’s a second example. This patient, also tall and strong with above average looks had raped two previous girlfriends and force them to give blowjobs at knifepoint. Yes, that’s right, twice. Someone had let him out after the first one and after some time had gone by, he couldn’t resist and did it again. He then should have never seen the light of day again and maybe he never did. But he’d learned, twice, that his mistake was leaving the victim alive to report him, so if some twisted solicitor ever did convince a tribunal to discharge him, can anybody guess what he’d do the third time?
Ok, those two are pretty severe examples. There are plenty of patients out there who aren’t killers or rapists in waiting. But still, once they’ve refused their depot a few times or decided they don’t need their tablets anymore, they can become neighbours from hell, paranoid, and violent.
Some lesser examples.
The man (delusional disorder) who knew without a shadow of doubt that his elderly neighbour was somehow making his TV reception go wobbly and that for such a crime, the only suitable punishment was to be beaten unconscious.
The Borderline woman who lashes out unpredictably and randomly at passers-by in the street. When she leaves the comfortable, all goodies supplied, free supported accommodation to go out in public, she has to be escorted by two staff. It doesn’t make a jot of difference to her assaults. Those staff, you see, are not allowed to do anything stronger than give words of discouragement. Years of mental-get-out-of-jail-free-cards have shown her she is untouchable.
That is baseline for those two. The woman could have been taught (earlier in life, using school of hard knocks methods, including merciless and consistent arrest, prosecution, conviction and punishments that hurt) self-control, that actions have consequences, that other people also have rights. Too late now, the wool has been well and truly dyed.
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