The British Journal of Psychiatry (2014)

205, 497–501

Correspondence
by suggesting that our patients are somehow less deserving of a
psychiatric diagnosis than a physical diagnosis’. Then, just in case
Edited by Kiriakos Xenitidis and we are still equivocating, using the College’s Good Psychiatric
Colin Campbell Practice to bring us into line (as if this too was some ahistorical
and acultural document), they pronounce: ‘This [use of standard-
ised diagnosis] is not an issue of personal choice for a practitioner.
Contents It is a professional responsibility to the patient’. Their penultimate
& Craddock and Mynors-Wallis’s assault on thinking reference (entitled ‘Time to end the distinction between mental
and neurological illnesses’) betrays their own ideological foray.
& Concerns regarding an evaluation of MTFC-A
Of course, if diagnosis is understood in the broader sense of a
for adolescents in English care
thoroughgoing, descriptive and summative attempt at understanding
& Are we reinforcing the anti-medical model? a patient’s struggles, respectful of personal meaning and unblinded
& Electronic monitoring of forensic patients to issues of power and social context (the latter often being harder
to change than biology, in which it may then of course be reflected7),
then we too might endorse Craddock and Mynors-Wallis’s position.
But in terms of a reverence to standardised manuals (whether DSM
Craddock and Mynors-Wallis’s assault on thinking or ICD) that lack true nosological validity, even by their own
The validity and utility of psychiatric diagnoses have long been a standards, and whose utility is at best questionable,8 and which
bone of contention between and within different professional and in effect serve to obscure key psychosocial antecedents,7 we would
patient groups. This was clearly shown by the nearly 70 rapid also argue that our patients deserve better.
responses to a 2001 BMJ article that proposed that post-traumatic There is little space for wider critique (for this, see Timimi8)
stress disorder was a social construct with little clinical utility.1 and discussion of alternatives here, but if mature science is
The reponses were emotive and polarised, with an equal comfortable with dissent and debate (and indeed sees this as
proportion of patients and professionals in each camp: those necessary for progression) this editorial seems a misplaced
who felt diagnoses were important and life-changing, and those attempt to close down discussion – first through unsubstantiated
who felt outraged and negated by the medicalisation of social emotive appeal, then through the threat of professional censure –
suffering. In their recent editorial Craddock and Mynors-Wallis2 in order to maintain a façade of professional consensus. While we
frame this diagnostic debate in terms of ‘benefits and limitations’; might wonder what lies behind such a move, we would advocate a
possible ‘disadvantages’ are acknowledged but mention of more far-reaching attempt at embracing complexity. In particular,
potential harms is conspicuously absent. as we have argued elsewhere,3 in attending to issues of power,
They advocate ‘embracing complexity’, but for the rest of their meaning, social context and the therapeutic alliance, alongside
article this does not ring true. They reel off the standard list of but not reduced to biology, we have much to offer the rest of
apparent advantages to diagnosis – providing reassurance and medicine, which is also beginning to grapple with related issues.9,10
reducing blame, shame and stigma – but without reference to 1 Summerfield D. The invention of post-traumatic stress disorder and the
research findings. (Nowhere in their paper is any patient-led or social usefulness of a psychiatric category. BMJ 2001; 322: 95–8.
collaborative research cited.) Also conspicuously absent in their 2 Craddock N, Mynors-Wallis L. Psychiatric diagnosis: impersonal, imperfect
and important. Br J Psychiatry 2014; 204: 93–5.
list is the necessity of a diagnosis to guide treatment. Is this a tacit
3 Bracken P, Thomas P, Timimi S, Asen E, Behr G, Beuster C, et al. Psychiatry
acknowledgement that there is little evidence to support such a claim beyond the current paradigm. Br J Psychiatry 2012; 201: 430–4.
and that, in mental healthcare at least, ‘common factors’ linked to the 4 Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic
therapeutic alliance, alongside extra-therapeutic factors, explain the explanations and public acceptance of mental illness: systematic review of
majority of treatment variance?3 In spite of this, they then go population studies. Br J Psychiatry 2011; 199: 367–72.
on to assert ‘there are no issues about diagnosis (or indeed treat- 5 Littlewood R. Pathologies of the West: An Anthropology of Mental Illness in
Europe and America. Continuum International Publishing Group, 2002.
ments) that are unique to psychiatry’ (for the counter-argument
6 Barrett RJ. The Psychiatric Team and the Social Definition of Schizophrenia: An
see Bracken et al3 and related correspondence). Anthropological Study of Person and Illness. Cambridge University Press, 1996.
Their erroneous linkage between diagnosis and stigma reduction 7 Krieger N. ‘Bodies count’, and body counts: social epidemiology and
stands out as particularly misleading. There is now an abundance of embodying inequality. Epidemiologic Reviews 2004; 26: 92–103.
evidence, including a comprehensive review published last year in 8 Timimi S. No more psychiatric labels: campaign to abolish psychiatric
this journal,4 that biomedical framing of mental illness tends to diagnostic systems such as ICD and DSM. Self & Society 2013; 40: 6–14.

increase personal and social stigma and public desire for distance. 9 Das A. The ‘rest of medicine’ and psychiatry: why paradigms would differ.
Br J Psychiatry 2013; 202: 463.
The authors may counter that a diagnosis does not imply
10 Sharpe M. Psychological medicine and the future of psychiatry. Br J
biological causality, and they seem to endorse the standard Psychiatry 2014; 204: 91–2.
biopsychosocial frame of reference. The problem is, as Roland
Littlewood5 points out, it is more or less impossible to hold a James Rodger, South Devon CAMHS, Devon Integrated Children’s Services, Exeter,
email: [email protected]; Sami Timimi, Lincolnshire Partnership NHS Foundation
‘personalistic’ view of the self as agentic and intentional while at the Trust Child and Family Services Horizons Centre, Lincoln; Joanna Moncrieff,
same time subscribing to a ‘naturalistic’ view of being a product of Department of Mental Health Sciences, University College London, London; Graham
Behr, Central and North West London Foundation NHS Trust, London; Carl Beuster,
biology, or even of the environment. One position always elides into independent psychiatrist, UK; Pat Bracken, Centre for Mental Health Care and
the other. If this is true for professionals, it is certainly true for Recovery, Bantry General Hospital, Bantry, Ireland; Ivor Browne, University College
Dublin, Dublin, Ireland; Chris Evans, East London NHS Trust, London; Suman
patients. And the dominant cultural understanding of diagnosis Fernando, Faculty of Social Sciences & Humanities, London Metropolitan University,
is that of biology, as it is with de facto psychiatric practice.6 London; Rhodri Huws, Eastglade Community Health Centre, Sheffield; Bob
Johnson, Quay Street Clinic, Isle of Wight; Navjyoat Kingsnorth, consultant
Craddock and Mynors-Wallis seem to want to be reasonable; psychiatrist, Galway, Ireland; Brian Martindale, private practice, Newcastle upon
identifying themselves, with other psychiatrists, as ‘reflective and Tyne; Hugh Middleton, School of Sociology and Social Policy, University of
Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham; Derek
tolerant of strongly opposing views and ideologies’. First, however, Summerfield, CASCAID, Maudsley Hospital, London; Philip Thomas, University of
they resort to an unsubstantiated moral and emotive appeal to their Bradford, Bradford, UK; Jeremy Wallace, HUS, Peijas Hospital, Vantaa, Finland.
position: ‘This can be to our patients’ disadvantage if we allow these doi: 10.1192/bjp.205.6.497
views [i.e. critical of standard diagnostic practices] to be unopposed

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Authors’ reply: The letter from Rodger et al uses our editorial weights was applied and after elimination of cases with probability
to rehearse the well-worn arguments of the small group of of assignment to MTFC-A above 0.95 and below 0.05. Depending
so-called ‘critical psychiatrists’ who are active and vocal in on the distribution of assignment probabilities, this may have
criticising core aspects of the practice of psychiatry as a medical resulted in relatively limited ‘data trimming’ in order to attain
subspecialty underpinned by science. The views expressed in the desired allocation probabilities near 0.50. The observed differences
letter are mainly tangential to the views we expressed in our included not only age but also the primary outcome scores.
editorial and the authors have made assumptions and accusations Notwithstanding concerns regarding statistical power for the
that are unsupported by our text. trial, the authors reported intervention by baseline risk inter-
We are very keen to encourage informed and constructive actions in the only adequately powered arm of the study (see Table
debate to advance patient care and mental health. However, it is 5). Given prior demonstration of MTFC-A intervention by
important to make a distinction between the freedom that is baseline risk interactions,2 these results may have been more
properly enjoyed in academic debate and the responsibilities that appropriately presented as a hypothesised replication. Statistical
come with professional practice. At present, those who work as power is also a concern for the reported analyses of offending;
psychiatrists are expected to practise in accordance with b = 0.034 to detect the observed ITT odds ratio of 1.24 using
evidence-based standards. The standards we adhere to will of an allocation of 20 and 14 cases, and b = 0.031 in the quasi-
course change over time as the evidence base develops. This is experimental arm to detect the observed ITT odds ratio of 1.07
expected by patients and colleagues and required by regulators. with 93 and 92 cases. Interpretation of effects should therefore
We continue to believe that our patients are best served by be treated with caution.
seeing psychiatrists who are trained to make a thorough We raise one additional point of clarification regarding prior
assessment, come to a diagnosis and shared formulation with MTFC-A implementations. The authors state that the context of
the patient of their problems and use this to draw up an intervention in the UK differs significantly from that in the
evidence-based management plan. It seems strange to us that this originating US studies, since ‘these were focused on convicted
should be surprising, contentious or upsetting to the authors of delinquent youth where the alternative [to MTFC-A] was
the letter. incarceration’, thereby concluding that the ‘control condition in
the US studies approximated [ . . . ] to juvenile custody’. Actually,
Nick Craddock, Department of Psychological Medicine and Neurology, similar to the usual care condition in the Green et al study, the
School of Medicine, Cardiff University, email: [email protected];
Laurence Mynors-Wallis, Alderney Hospital.
standard control condition in US MTFC-A studies is group care,3
not incarceration.
doi: 10.1192/bjp.205.6.498
We offer these points by way of lending interpretation to the
efficacy of Green et al’s results and to suggest caution in accepting
the conclusion that MTFC-A may not result in better outcomes
than usual care among at-risk adolescents in English care.
Concerns regarding an evaluation
of MTFC-A for adolescents in English care 1 Green JM, Biehal N, Roberts C, Dixon J, Kay C, Parry E, et al.
Multidimensional Treatment Foster Care for Adolescents in English care:
We are writing to highlight concerns regarding conclusions offered randomised trial and observational cohort evaluation. Br J Psychiatry
by Green et al in their evaluation of Multidimensional Treatment 2014; 204: 214–21.
Foster Care for Adolescents (MTFC-A) relative to usual care for 2 Leve LD, Chamberlain P, Smith DK, Harold GT. Multidimensional treatment
at-risk youth in English foster care.1 We commend the authors foster care as an intervention for juvenile justice girls in out-of-home care. In
for undertaking an independent review of MTFC-A. However, Delinquent Girls: Contexts, Relationships, and Adaptation (eds S Miller, L
Leve, P Kerig). Springer Press, 2011.
we offer some observations to help contextualise the efficacy of
the evaluation with respect to the primary conclusion that 3 Chamberlain P. Treating Chronic Juvenile Offenders: Advances Made through
the Oregon Multidimensional Treatment Foster Care Model. American
MTFC-A did not result in better outcomes than usual care. Psychological Association, 2003.
Green et al’s evaluation employed a two-arm, single-blinded
(assessor) randomised controlled trial embedded within an Conflict of interest: The authors have collaborated with US
observational quasi-experimental case–control study. An intent- colleagues on projects using the MTFC-A programme.
to-treat (ITT) analysis was employed specific to the MTFC-A
versus usual care comparison. The authors state that the study Gordon T. Harold, School of Psychology, University of Sussex. Email:
was intended to be powered at b = 0.80 to detect half a standard [email protected]; David S. DeGarmo, Prevention Science Institute, University
of Oregon.
deviation difference between ITT and usual care (with a target n
of 130), and was powered b = 0.95 to detect the same effect doi: 10.1192/bjp.205.6.498a

between ITT and usual care in the quasi-experimental study (with

a target n of 90). However, the target allocation for the trial was
not met. The trial randomly allocated only 34 participants Authors’ reply: Harold & DeGarmo correctly refer to points
(n = 20 MTFC-A and n = 14 usual care). Based on these numbers, regarding sample size and power that we already made in the
we estimate the study was actually powered at b = 0.29 in the ITT discussion section of our paper. Despite this, we did point to
analysis to detect half a standard deviation difference between the strengths of the study in the representativeness of the cohort
conditions assuming equal variances, and at b = 0.28 assuming within a real-world implementation setting, the fact that the study
unequal variances. was conducted independently of treatment originators and UK
Substantive conclusions therefore seem to be based on a implementation team, careful attention to triangulation and
substantially underpowered design (as far as we can tell from masked rating of primary outcome data (something often not
the detail presented in the original manuscript). Further, the undertaken in this kind of context), and the low attrition rates
quasi-experimental arm was described as a case–control design. to endpoint. We stated that the convergence of findings from
However, it was not a matched case–control design. This is our mixed-method design and the confidence intervals of the
evident from multiple baseline differences between groups, some outcome estimations gave some confidence to inferences from
of which remained after an intensive set of propensity-score the results.

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Harold & DeGarmo also question whether there was indeed a is potential to reinforce the idea that antipsychotic medication
difference in the standard control condition (usual care) for is harmful and unnecessary. We feel that this would further
participants in the US and UK studies. There are certainly likely disadvantage an already vulnerable group of patients.
to be differences in the nature and uses of group care between This issue has recently received a fair degree of coverage in the
the two countries, given the differences in their child-welfare media, with articles such as Freeman & Freeman’s piece in The
and juvenile-justice systems. However, the point we were making Guardian fuelling long-held popular beliefs that antipsychotics
is that, in the USA, the MTFC programme for adolescents has are ineffective and in fact damaging to health.5 Given the
been principally found to be successful when targeted at young well-documented drawbacks of antipsychotic drugs, it is
offenders, in studies that have used a variety of measures of understandable that patients and professionals will invest hope
recorded reoffending to assess its effectiveness.1–3 This emphasis in non-drug alternatives. However, a large meta-analysis with over
on the effectiveness of MTFC-A with young offenders is also clear 3000 participants shows at best a small effect size for CBT.6 In
from the programme developers’ own website (www.mtfc.com). reference to Penttilä et al’s paper, we would be interested to read
By contrast, the participants in our study were young people with subgroup analyses of specific first-line treatments and wonder if
complex emotional and behavioural difficulties, 93% of whom outcomes would differ between modalities.
were in care because of abuse or neglect and less than a third of While we would endorse any treatment, drug or non-drug
whom had a recent criminal conviction. The differences between based, that is proven to reduce DUP, it is vital that we do not lose
the populations served by MTFC-A are clearly evident in an article sight of the fact that antipsychotics are the only evidence-based
comparing outcomes for high-risk adolescent girls written by the first-line therapy in psychotic illness.
programme developers in the USA and their English colleagues4
and may perhaps partly explain why the results of the English eva- 1 Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J. Duration
of untreated psychosis as predictor of long-term outcome in schizophrenia:
luation were less positive than those in the USA. systematic review and meta-analysis. Br J Psychiatry 2014; 205: 88–94.
2 Leucht S, Arbter D, Engel RR, Kissling W, Davis JM. How effective are second-
1 Chamberlain P. Comparative evaluation of foster care for seriously
generation antipsychotic drugs? A metaanalysis of placebo-controlled trials.
delinquent youth: a first step. Community Altern 1990; 2: 21–36.
Mol Psychiatry 2009; 14: 429–47.
2 Chamberlain P, Reid JB. Comparison of two community alternatives to
3 Morrison AP, Hutton P, Wardle M, Spencer H, Barratt S, Brabban A, et al.
incarceration for chronic juvenile offenders. J Consult Clin Psychol 1998; 66:
Cognitive therapy for people with a schizophrenia spectrum diagnosis not
624–33.
taking antipsychotic medication: an exploratory trial. Psychol Med 2012; 42:
3 Leve L, Chamberlain P, Reid JB. Intervention outcomes for girls referred from 1049–56.
juvenile justice: effects on delinquency. J Consult Clin Psychol 2005; 75:
4 Tiihonen J, Lannqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A,
1181–4.
et al. 11-year follow-up of mortality in patients with schizophrenia: a
4 Rhoades K, Chamberlain P, Roberts R, Leve L. MTFC for high risk adolescent population-based cohort study (FIN11 study). Lancet 2009; 374: 620–7.
girls: a comparison of outcomes in England and the United States. J Child
5 Freeman D, Freeman J. At last, a promising alternative to antipsychotics for
Adolesc Subst Abuse 2013; 22: 435–49.
schizophrenia. The Guardian, 7 March 2014.
6 Jauhar S, McKenna PJ, Radua J, Fung E, Salvador R, Laws KR. Cognitive–
Jonathan Green, Professor of Child and Adolescent Psychiatry, University of behavioural therapy for the symptoms of schizophrenia: systematic review
Manchester and Manchester Academic Health Sciences Centre. Email:
and meta-analysis with examination of potential bias. Br J Psychiatry 2014;
[email protected]; N. Biehal, Department of Social Policy and Social
Work, University of York, York; C. Roberts, Centre for Biostatistics, Institute of 204: 20–9.
Population Health, University of Manchester, Manchester; J. Dixon, Social Policy
Research Unit (SPRU), University of York, York; C. Kay, Institute of Brain Behaviour
and Mental Health, University of Manchester, Manchester; E. Parry, Mood Disorders Dorothea C Bindman, Core Trainee, London Deanery, email: dorothea.bindman@
Centre, University of Exeter, Exeter; J. Rothwell, A. Roby, D. Kapadia, Institute of nhs.net; Mukesh Kripalani, Tees, Esk and Wear Valleys NHS Foundation Trust, UK.
Brain Behaviour and Mental Health, University of Manchester, Manchester; S. Scott,
Institute of Psychiatry, King’s College London, London; I. Sinclair, Social Policy doi: 10.1192/bjp.205.6.499
Research Unit (SPRU), University of York, York, UK.

doi: 10.1192/bjp.205.6.498b
Author’s reply: Dr Bindman and Dr Kripalani have suggested
an analysis of the association between DUP and outcomes in
subgroups by specific first-line treatment modalities. Unfortunately,
Are we reinforcing the anti-medical model? it was not possible to analyse this in our meta-analysis, since none
The results of Penttilä et al’s meta-analysis emphasised the of the original studies had used only one treatment modality, but a
importance of the duration of untreated psychosis (DUP) in combination of them in the early phases of treatment. As
long-term recovery from schizophreniform illness.1 Timely Bindman & Kripalani point out, and based on current knowledge
initiation of effective treatment has been demonstrated to improve of the efficacy of treatments in the early phase of schizophrenia, it
outcome, but the modality of treatment is currently under much would not be ethical to study treatment without antipsychotic
debate. Robust evidence exists for the efficacy of antipsychotic medication in a first-episode clinical sample.1 Also, DUP is usually
medication2 but recent studies have proposed psychological defined as ending at the initiation of antipsychotic medication,
interventions, specifically cognitive–behavioural therapy (CBT), which in clinical practice usually occurs about the same time as
as an alternative first-line treatment. other treatment modalities begin; therefore, the included studies
In a recent randomised controlled trial, CBT was used as a single give only a little information on the effects of different treatments.
intervention, instead of conventional antipsychotic treatment.3 To However, it is interesting to note that de Haan et al 2 investigated
our complete surprise, one of the exclusion criteria was treatment the effect of delay in intensive psychosocial treatment by comparing
with antipsychotic drugs. We wonder how ethical approval was this effect with delay in treatment with antipsychotic medication;
granted, despite Tiihonen et al’s robust demonstration of reduced and found that delay in psychosocial treatment may be a
mortality over a considerable follow-up period for patients more important predictor of negative symptoms than delay in
receiving antipsychotic medication.4 We feel that this will set a antipsychotic treatment.
dangerous precedent of offering psychological treatment as an The discussion about the possible effects of antipsychotics has
alternative to evidence-based treatment. In a clinical setting, been rather intense recently. However, the current guidelines for
adherence to drug treatment is already a significant issue and there treatment of psychosis and schizophrenia clearly indicate that

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antipsychotic medications are effective and recommended its effectiveness during use, such as on bail or as an alternative
treatment for active psychotic symptoms,1 though there is not to incarceration, usually combined with home detention.
so much evidence for the long term (i.e. several years of Electronic monitoring combined with home detention is superior
antipsychotic treatments3). Additionally, the clinical use of these to imprisonment in these studies, but we already know that non-
medications is not always straightforward because of their known custodial responses to crime in general have superior outcomes to
side-effects and the fact that, in all psychiatric disorders and other incarceration (see, for example, Wermink et al 2).
illnesses in medicine, there are always patients who do not want to We know very little about outcomes after the use of electronic
take the recommended treatment. This seems to have been the monitoring. Although the use of global positioning satellite (GPS)
case in the trial pointed out by Bindman & Kripalani.4 When technology might improve the person’s performance in following
considering the long-term effects of antipsychotics, it is evident rules, it is not clear that this sort of rule following encourages the
that the long-term treatment of psychosis needs to be developed person in the ultimate tasks of forensic rehabilitation. Does it
further. improve the therapeutic alliance to help the person make the life
We agree that it would be dangerous to see different changes necessary to recover from illness and illness-related
treatments as alternatives to each other, and it has been shown offending? Or does electronic monitoring seem a physical
that in psychiatry a combination of different treatments is, in manifestation of distrust and create distance between the patient
general, more effective than any of them alone.5 Psychotherapy and the treatment team? If the only way that a person can safely
in the early phase of illness could be effective not only in have community contact is to wear an ankle bracelet, isn’t it
preventing psychosis at prodromal phase, but also in enhancing questionable whether they are ready for that level of community
adherence to antipsychotic medication.1 Current treatment contact? Electronic monitoring may allow the person more
guidelines do not suggest that treatment of first-episode psychosis apparent personal freedom than their clinical risk would otherwise
should include only antipsychotic medication without psycho- allow. As Tully et al point out, adoption of the GPS technology
social treatment, but rather state that medication is one of the may seem appealing, but its costs and effects are not clear and
cornerstones of psychosis treatment. We believe there is still a neither is its impact on therapeutic and community
lot to do in developing both medication and psychosocial engagement. Short-term reductions in absence without leave
treatments for schizophrenia, and hopefully active research can might give the appearance of progress that the patient has not
support this development. actually achieved. Long-term outcome is equally as important as
1 National Institute for Health and Care Excellence. Psychosis and
short-term adherence.
Schizophrenia in Adults: Treatment and Management (Clinical Guideline 1 Tully J, Hearn D, Fahy T. Can electronic monitoring (GPS ‘tracking’) enhance
178). NICE, 2014. risk management in psychiatry? Br J Psychiatry 2014; 205: 83–5.
2 de Haan L, Linszen DH, Lenior ME, de Win ED, Gorsira R. Duration of 2 Wermink H, Blokland A, Nieuwbeerta P, Nagin D, Tollenaar N. Comparing the
untreated psychosis and outcome of schizophrenia: delay in intensive effects of community service and short-term imprisonment on recidivism: a
psychosocial treatment versus delay in treatment with antipsychotic matched samples approach. J Exp Criminol 2010; 6: 325–49.
medication. Schizophr Bull 2003; 29: 341–8.
3 Harrow M, Jobe TH, Faull RN. Does treatment of schizophrenia with
Alexander I. F. Simpson, Chief of Forensic Psychiatry, Stephanie R Penney,
antipsychotic medications eliminate or reduce psychosis? A 20-year Centre for Addiction and Mental Health, email: [email protected]
multi-follow-up study. Psychol Med 2014; 44: 3007–16.
doi: 10.1192/bjp.205.6.500
4 Morrison AP, Turkington D, Pyle M, Spencer H, Brabban A, Dunn G, et al.
Cognitive therapy for people with schizophrenia spectrum disorders not
taking antipsychotic drugs: a single-blind randomised controlled trial. Lancet
2014; 383: 1395–403.
Tully and colleagues1 justify the introduction of electronic
5 Cuijpers P, van Straten A, Warmerdam L, Andersson G. Psychotherapy versus
monitoring of medium secure patients without indication of the
the combination of psychotherapy and pharmacotherapy in the treatment of
depression: a meta-analysis. Depress Anxiety 2009; 26: 279–88. size of the problem of absconding or the incidence of serious harm
other than to reference an article in The Sun newspaper, which is
Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University
neither informative nor free of bias.
Hospital, email: [email protected]; Erika Jääskeläinen, Noora Hirvonen, Decisions around leave for patients detained within a medium
Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University
Hospital and Medical Research Center Oulu, Finland.
secure unit are clearly complex. Consideration should always be
given to the risk of absconding and associated risks if the patient
doi: 10.1192/bjp.205.6.499a
were to abscond. Thus, patients who are at high risk of absconding
and a serious risk to the public would not receive leave, whether
they were tagged or not. Another factor is the clinical team’s trust
Electronic monitoring of forensic patients in that patient to use leave appropriately. Tagging patients would
Tully et al raise important questions about the introduction of be a very clear indicator of a lack of such trust.
electronic monitoring of forensic patients.1 Incidents of The suggestion that patients enter into electronic monitoring
absconding by forensic patients can give rise to calls for increased with consent is questionable: many patients in our experience
security and surveillance. As the authors point out, adoption of abide by suggestions of their clinical team in order to progress
electronic monitoring as a panacea for these problems is short- through the system. Given that there is yet to be a strong
sighted. Tully et al cover many of the concerns about electronic argument that tagging is necessary and primarily in the patient’s
monitoring but one area is missing: that the evidence we have best interest (as opposed to a matter of public protection), can
from electronic monitoring in the criminal justice sector is one justify this coercion? We would be very interested to know
primarily of its effects on recidivism and absence without leave the process in which patients’ perspectives were taken into account
during use; evidence is very limited on the effects after its use. and whether this has altered the intervention.
In other words, electronic monitoring must eventually cease. Is Electronic monitoring would inform the clinical team if the
the use of electronic monitoring during community reintegration patient were to breach the conditions of their leave in terms of
actually preparing the patient for greater freedom and their approximate location and time of leave; however, it would not
rehabilitation, or simply delaying reoffending? Criminal justice inform the team as to what that patient was doing with their leave
experience with electronic monitoring focuses almost entirely on and would not necessarily prevent serious incidents occurring, as

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suggested. The use of a device whose main purpose has been risk for absconding or not is again overly simplistic. Clinical
pioneered by the criminal justice system seems to take us closer impression alone in risk assessment has been shown to be
to making our hospitals prisons. A recent report published by unreliable and validated risk assessment tools have been shown
the Criminal Justice Joint Inspection reiterates their 2008 findings to be more useful in identifying individuals at low rather than
that enforcement thresholds were not sufficiently stringent.2 With high risk.1 No validated tool for the assessment of absconding risk
notable problems implementing this system within the criminal yet exists, though we are currently working on developing one.
justice system, is it justifiable to implement it within the forensic Risk management, therefore, involves a component of positive
services, given the cost of such a system?3 risk-taking aided by creative management strategies. We propose
Given the recent concerns about certain international security that electronic monitoring is such a strategy.
companies, the provision of such tags also raises ethical issues. Watson et al are liberal in their use of the term ‘coercion’. A
Confidentiality must also be considered – would said companies policy was put in place whereby patients were informed that use
have access to patient names and locations? The comparison of of electronic monitoring was optional and if they chose to decline
electronic monitoring with other uses of technology within to wear the device, their leave would be risk assessed as per normal
psychiatry, such as mood monitoring via text message, is bizarre. procedure. Consent is another complex issue in psychiatry and
The principles approach4 gives us a framework in terms of judging can be defined in degrees, rather than as a binary concept.2 It
whether an intervention respects autonomy, beneficence, non- is true that patients’ decisions about consent to electronic
maleficence and justice. Debate of these principles will exceed monitoring are likely to be influenced by their wish to move more
the remit of this letter; however, it is worthwhile considering quickly towards leave and discharge. This has parallels with
autonomy and beneficence in particular relating to the patient: consent to medication and engagement in psychotherapies and
we suggest that there is a breach in both. The weighing of these occupational activities, particularly in the forensic setting.
principles will not be easy and it will be a matter of debate whether Watson et al express concern about forensic services being
the principle of justice will outbalance the former. closely aligned with the prison system. We believe that the use
As the authors state, robust research in this area is needed, and of secure units with locked wards and secure perimeters represents
we look forward to reviewing the evidence. a level of coercion much more closely aligned to this system than
does electronic monitoring. Any strategy that can help minimise
1 Tully J, Hearn D, Fahy T. Can electronic monitoring (GPS ’tracking’) enhance the amount of time spent in such units would then surely be a
risk management in psychiatry? Br J Psychiatry 2014; 205: 83–5.
welcome development for those concerned about patient liberty
2 HM Inspectors of Probation. It’s Complicated: The Management of
Electronically Monitored Curfews. Criminal Justice Joint Inspection, 2012.
and overall progress. Far from making our units more like prisons,
one of the key aims of our strategy was to allow for engagement in
3 Shaw D. Satellites used to track mentally-ill violent criminals. BBC News, 25
August 2010. community leave and activities at the earliest possible stage. As
4 Gillon R. Philosophical Medical Ethics. Wiley, 1985. Simpson & Penney point out, electronic monitoring may allow
the person more apparent personal freedom than their clinical risk
Eleanor Watson, ST5 Forensic Psychiatry, email: [email protected],
would otherwise allow.
Purvesh Madhani, ST5 Forensic Psychiatry, Shari Mysorekar, Specialist Registrar The article referenced in The Sun was chosen as an example of
Forensic Psychiatry and Psychotherapy, Kirsty Sollitt, ST6 Forensic Psychiatry, media coverage of such absconding events. That such reports are
Yorkshire Centre for Forensic Psychiatry, South West Yorkshire Partnership NHS
Foundation Trust. often sensationalised or biased is one of the many challenges
facing mental health services and patients. Media coverage of
doi: 10.1192/bjp.205.6.500a
absconding events leads to reputational damage for services and
can undermine the confidence of the community. We cannot
and should not ignore community attitudes towards system
Authors’ reply: We had hoped that our article would stimulate
breaches, especially as clinicians will be held to account when they
a balanced discussion about this complex issue. We entirely agree
occur. Another of our aims is therefore to reduce the frequency of
with the view expressed in both letters that trust and therapeutic
these incidents, for the protection of the public and the reputation
alliance between the patient and the treating team are critical
of our service.
components of the recovery process. We do not believe, however,
Watson et al are correct in saying that electronic monitoring
that use of electronic monitoring necessarily indicates a lack of
cannot directly prevent violent incidents. We believed that this
trust. It was envisioned that the device be used primarily for
was self-evident and therefore we did not address this issue in
patients in the initial stages of taking leave as part of their clinical
our article. Regarding costs, a cost–benefit analysis is currently
pathway towards discharge into the community. Our clinical
underway. As our article states, our service was acutely aware of the
experience, supported by as yet unpublished data, confirms that
important ethical considerations and we sought legal and ethical
this has been the case in our service. In these circumstances,
advice. A commentary addressing legal and ethical issues in more
electronic monitoring may even help to further develop a trusting
depth is currently being prepared. The questions Simpson &
relationship between the wearer and the team, by granting earlier
Penney raise about reoffending, recovery and longer-term outcomes
and more frequent leave and by allowing the patient to
are valid and we hope to address these in our future research.
demonstrate avoidance of exclusion zones when on unescorted
leave. There must be a balance between trust and therapeutic 1 Fazel S, Singh JP, Doll H. Use of risk assessment instruments to predict
optimism in our treatment of our patients. Furthermore, viewing violence and antisocial behaviour in 73 samples involving 24 827 people:
systematic review and meta-analysis. BMJ 2012; 345: e4692.
trust as being simply ‘present’ or ‘absent’ would be a naive
2 Konow J. Coercion and consent. J Inst Theor Econ 2014; 170: 49–74.
approach in forensic services. These questions are being explored
in quantitative and qualitative research of electronic monitoring in
our service. John Tully, Forensic Psychiatry Service, South London and Maudsley NHS
Foundation Trust, email: [email protected]; Dave Hearn, Thomas Fahy,
Both letters raise concerns about granting of leave for high- Forensic Psychiatry Service, South London and Maudsley Foundation NHS
risk patients. Watson et al point out that decisions surrounding Trust, UK.
leave are complex, a view that we share. However, the implied view doi: 10.1192/bjp.205.6.501
in both letters that patients can be discretely classified into high

501
Craddock and Mynors-Wallis's assault on thinking
James Rodger, Sami Timimi, Joanna Moncrieff, Graham Behr, Carl Beuster, Pat Bracken, Ivor Browne,
Chris Evans, Suman Fernando, Rhodri Huws, Bob Johnson, Navjyoat Kingsnorth, Brian Martindale, Hugh
Middleton, Derek Summerfield, Philip Thomas and Jeremy Wallace
BJP 2014, 205:497.
Access the most recent version at DOI: 10.1192/bjp.205.6.497

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