Managing Clients with
Psychiatric Disorders
Tony Glynn & Ian Curtis
Queensland Law Society
Soft Skills Series
Thursday 7 April 2005
Disclaimer

Criminal activity no more likely within mentally ill
populations than in the general population.

Mental illness in a person does not predispose
to crimes against persons or property.

There are occasions of causal relationship
between mental illness and some unlawful acts.
Psychosocial

Every crime occurs in a psychosocial context.

It may be important for the Court, within the
limits presumably of what is more probable than
not, to know of the psychosocial context and the
relevance of the person’s life course to a
particular criminal or accidental event.

Explanation or excuse? (P Shea, 1993)
Workplace Injuries




The same issues can be raised about the
psychosocial backdrop to an accident in the
workplace.
Often more complex.
Factors within the life course of the employing
entity are relevant as well as complainant factors.
It requires two people to make a mistake at the
same time for an accident to occur.
Mental Health Gatekeepers

Mental health gatekeepers include police, clergy,
and legal professionals amongst others because
these groups all have training in observation and
substantial contact with people.

So we could rename this presentation: Mental
Health Awareness/Gatekeeping.
Presentations of People with
Mental Health Harms

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Threat towards the self (suicide/parasuicide) or
towards another.
Covert (masked) illness.
The swapping of types of suffering (eg depression/
alcohol).
Major assault on one or more people.
Colleagues in trouble with their mental health. Are
we sufficiently aware and active? Doctors are not!
Principles for Handling Overt
Aggression

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The non-reciprocal approach to threat of
violence to minimise harms.
A violent man is a frightened man and how this
helps you in confronting threat.
Office architecture.
Office crisis plans.
Self-defence, bearing in mind that the best selfdefence ever invented was running away.
Health and Safety Responsibilities
to Support Staff



The healthy workplace.
Safety of staff.
Issues:
 Duress
alarms
 Procedures for warning neighbouring staff and other
offices of hazardous behaviours
 Evacuation plans to deal not just with fire but also to
deal with behavioural dangers and violence
Health & Safety Comments

If no crisis plan exists at the subject time, a crisis
is not the time to be inventing the plan.

The colleague next to you must have an idea
what you are likely to do.

If there is a plan in place, there is at least some
chance that some people will keep to it.
Legal Professional Management

All have your own preferred methods for
assessing clients.

We all have different practices depending largely
on how we self-select client base.

This means that we all have differing
experiences of professional practice, even within
professions.
National Mental Health Survey

This 1997 work was a detailed overview of the
prevalence of mental and substance-use
disorders for Australia.

In line with the 1990 United States national
comorbidity survey.

In line with the 1993 United Kingdom survey of
psychiatric morbidity.
National Mental Health Survey
Questions

How many adults in private households suffered
from mental disorders?

How disabled were they by their psychiatric
impairment?

What health services did they use and want?
Disability

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People with mental disorders reported 14 million
disability days each month.
Mental disorders account for 20% of the total burden
of disease in Australia.
Expenditure on mental health is only 5% of the total
health budget.
Half the disability associated with mental disorders
is generated by two related disorders – the anxiety
and affective (mood) disorders
10% is generated by one disorder – schizophrenia.
Australian Mental Health 1997

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23% of adults reported having at least one
psychiatric disorder in the previous 12 months.
14% were suffering from a disorder when
interviewed.
35% had actually consulted about it.
50% of those disabled or having multiple
comorbidities had consulted.
The total prevalence in the year was 22.7%
using the ICD-10 and 20.3% using the DSM-IV.
Other Aspects

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Women had higher rates of mood and anxiety
disorders and lower rates of substance use
disorders in contrast to men.
The elderly had lower rates for all disorders
except cognitive impairment.
The young had much higher rates of substance
use disorders.
Currently married had lower rates for all
disorders.
Other Aspects (cont’d)


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Disorders frequent with less education.
Those employed had lower rates.
About 4% of people admitted to suffering from
2 or 3 or more diagnoses at the same time
(comorbidity).
Prevalence of Disorders in Men
7.10%
Anxiety
Depression
11.10%
Substance Use
4.20%
Prevalence of Disorders in Women
4.50%
7.40%
Anxiety
Depression
Substance Use
12.00%
Suicide
Suicide is the leading cause of death amongst
adult offenders in custodial settings. Inmates are
up to ten times more likely to die from suicide than
their counterparts in the general population.
Custody-related deaths may account for up to
three-quarters of all deaths amongst custodial
clients who have not yet gone to trial and up to
one-third of all deaths amongst sentenced
prisoners.
Last 100 Consecutive Medicolegal
Cases of Ian Curtis
19
20
18
16
13
14
12
9
10
7
8
5
6
4
2
2
3
0
4
5
3
5
4
1
2
3
3
2
3
1
22
00
2
00
0
0
'10-19
Age in Years
20-29
30-39
Female-Criminal
40-49
50-59
Female-Compensation
60-69
Male-Criminal
70-79
Male-Compensation
Last 100 Cases – By Type
3%
Bail Application
1%
Parole Application
34%
Criminal Case
Fitness for Trial
1%
1%
5%
55%
Children's Court
Family Court
Compensation
Last 100 Cases – By Gender
60
55
50
40
30
19
20
15
11
10
0
Male
Female
Criminal
Compensation
Last 100 Cases – By Age
25
22
20
17
15
11
11
10
5 5
6
6
7
4
5
2 2
2
0
0
'10-19
20-29
30-39
40-49
Age in Years
50-59
60-69
Criminal
70-79
Compensation
Last 100 Cases – By Global
Assessment of Functioning Scale*
3
not given
unknown
1
8
81-90
71-80
16
61-70
16
38
51-60
14
41-50
31-40
3
1
21-30
0
5
10
15
* DSM-IV Scale of Personal Functionality
20
25
30
35
40
Medical-Psychiatric Intervention
at Legal Practice Level

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Early detection is better.
Substantiation of expert opinion is of importance to the
Court.
The commissioning letter is vital. The commissioning
letter must pose clearly the questions that you require
to be answered.
The question of professional fees.
A personal and family history together with a plea for
mercy in the last paragraph is not a medicolegal report.
References
Andrews G, Henderson S, and Hall W (2001) ‘Prevalence, Comorbidity, Disability, and Service
Utilisation: Overview of the Australian National Mental Health Survey’ British Journal of
Psychiatry, 178, pp145-153.
Henderson S, Andrews G, and Hall W (2000) ‘Australia’s mental health: an overview of the
general population survey’ Australian and New Zealand Journal of Psychiatry, 34, pp197205.
Shea P (1993) Psychiatry in Cour,t Sydney: The Institute of Criminology.
Stuart H (PhD) (2004) ‘Suicide in Custody’ in Fast Facts – Psychiatry Highlights 2003-04
Malcolm Lader (ed), Oxford: Health Press Limited.
Treatment Protocol Protocol (2000) Management of Mental Disorders (3rd Edition). Sydney:
World Health Organization Collaborating Centre for Mental Health and Substance Abuse.