[Music] Hello and welcome to another episode of Evolving Prisons with me, Kagan Kari. If you want to listen to monthly bonus episodes, you can subscribe for only £3 per month by hitting the link in the show notes. Before we jump into today's episode, I'd be really grateful if you'd please rate the podcast on whatever platform you listen, as more ratings mean more people will discover the show. My guest today is Dr. Ben Cave. Dr. Cave is one of the UK's leading forensic psychiatrists, with 35 years' experience including as a prison psychiatrist and a consultant in secure and general mental health units. He is also the author of What We Fear Most, a psychiatrist journey to the heart of madness. Today, we discuss how schizophrenia affects around 1 in 100 people. Dr. Cave's thoughts on the fact that the Mental Health Act does not apply in prison. The risk of being a forensic psychiatrist where Dr. Cave had a security alarm link to the police installed in his home, and an interesting concept he has around some drug addicts being prescribed their drug to reduce harm to themselves and society. I hope you enjoy this conversation. [Music] So, first question that you probably always get, why did you decide forensic psychiatry as your area of specialism? Why did I decide to do forensic psychiatry? I'm not sure I did. I think I chose to do psychiatry. I was a very young 13, 14-year-old, and my father was in business. He was a former teacher. I had a big brother who by this stage was just going off to university to study law. He never actually completed the course. I think there was a big expectation to move into some sort of academic endeavor. I think my parents had never received the education they deserved for all sorts of reasons, poverty, Victorian upbringing sort of stuff. I remember a discussion with my father when I was 13, 14, and he said, "What are you going to do, Ben? What are you going to do with your life?" He went through a list of options, and I thought, "Well, I want to be a doctor, and it just kind of resolved." The moment I decided I wanted to be a doctor, I thought, "Well, I want to be a psychiatrist." In truth, I think that's because I thought psychiatry was easy. I thought I knew it all at the age of 13 or 14. I suppose that gets the heart of the question that I think it's because my mother was anxious, depressed. I grew up in the shadow of an uncle, killing himself. Another uncle had autism, as I would now describe it. He was just an oddball back then. Another had a quite a serious learning disability. I grew up in this sort of household where mental illness, mental disorders was present and not spoken about. I suppose that was key to my formative experiences. It's interesting you say you thought it would be easy because from reading your book, what we fear most, I think psychiatry sounds like it would probably be the most difficult part of medicine. I think it could be wrong, but we'll get into this later. Some of the stories that you're sharing your book where you talk about allegations made by patients who have delusions. Also, most people go to a doctor and we think they're going to help us. Whereas a lot of your patients don't even think there's anything wrong with them. So I think it would be very difficult actually to be a psychiatrist. I think you're right, Kagan. As I said, I was a fairly immature, 13, 14-year-old kid. I didn't know what I didn't know to sort of couch it in Rimsfeld terms. I think psychiatry is, well, for me, it's not the most difficult part of medicine. I think that for me, probably the difficulties you'd encounter in acute pediatric care oncology where people have severe life-threatening, life-changing injuries that are acute and need urgent intervention. I think for me that I would find that personally difficult. I suppose I became kind of used to the concept of chronic, sometimes debilitating conditions, which is what characterizes so many psychiatric disorders. I think it was only as I got older and perhaps started to have the spots knocked off me with age, with experience, with adverse experience sometimes. That I realized that psychiatry is difficult, it's complex, and it's an ever-changing beast. And I think that what I've seen over the last 35 years of practice is that things have changed. I think we're talking about it more, but perhaps more in terms of mental health rather than mental illness. When I went into it unashamedly, looking at mental illness, severe mental illness like schizophrenia, bipolar disorders. And although there is a wide range of issues in psychiatry, I was never personally that drawn to the anxiety states, the hyperkondriocese, the obsessive compulsive disorders, hugely important issues, but in a sense, I think I was looking for something that was outside of my own personal experience, because I grew up with quite significant ACD, quite significant anxiety and more than my fair share of depression. And I think for me, I was looking for something outside of myself. I didn't want to treat me all the time, and I possibly needed the external constraints, the rules of engagement, the mental health act. Issues where perhaps the court had determined guilt once I went from general psychiatry into forensic psychiatry. And coming back to your earlier question, forensic psychiatry was attractive because although I was fascinated by general psychiatry and the medical aspects of that, it kind of lacked for me. And what I loved about forensic psychiatry for so many years was actually that the interface with the other professional groups that involved the criminology, the sociology, the politics of it, the governance of prison environments. And it was all of those coming together with psychiatry, medicine, urology, a study of dependency disorders and social theories around that that I was actually very attracted to it. So it was the multiplicity of problems that has always attracted me in medicine. I've always been mentally switched on by the complexity. The more complex the case, the better for me. Okay, that's really interesting. And it's interesting that you mentioned, you mentioned this in your book too, that you didn't want to treat what issues you had. You wanted to go into something that you were detached from. And I think this is a maybe quite naive position from me when I was reading your book. I didn't realize that so many people who society would consider as being high flying respectable people, such as one of your colleagues, a forensic psychiatrist. You also mentioned somebody who was a philosophy, like throughout university. I didn't quite appreciate that anybody could be impacted by schizophrenia. I didn't realize that one in 100 people can get schizophrenia. I assumed people who had bipolar disorder schizophrenia and other neurological conditions like that were born like that. And we're never really able to flourish. And I appreciate that's a really naive position, but that really opened my eyes learning about that in your book that it can really happen to anybody. It makes me question, as a society, why is there so much stigma around these conditions when it really can happen to anybody at any time? Well, first of all, I'm pleased that you learned something and took something away from it. I think that when people learn schizophrenia affects around 1 in 100 people. And actually lifetime prevalence of psychosis is much higher than that, probably three or four times higher. Any of us might have a psychotic experience three and 100 times in our life. Bipolar disorder is probably higher. It's probably around 1.4%. And it's interesting you associate or did before reading the book that it was high flying and respectable people not having mental disorders. And I think this is an ingrained aspect of our society where we associate schizophrenia, particularly with an attitude of behavior, which is less than wholesome or good. I had this even yesterday when I was talking to a patient who undeniably had schizophrenia. He had paranoid schizophrenia every day of the week. He'd been on well for 30 years. He'd probably had a dozen or so admissions when he was unwell. He was threatening, aggressive, thought disordered. He thought that the world owed him millions of pounds for his great works and social theories. He'd written it down. He'd tried to publish books. So he had grandiose paranoid persecutory ideas. He hallucinated nearly continuously when he was unwell. And when he became well with the medication that had to be enforced upon him. He got better and then almost invariably he would stop taking his medication again. And when he did, he would simply relapse. And when I said, so tell me about the previous admissions, he said, it's all a big mistake. And this is so characteristic of schizophrenia. And then most interestingly, he said, of course schizophrenia, you just carry an knife around and you attack people. That's what schizophrenia is. And I think that's true of so many people that we associate, perhaps because of the news stories we hear, mad psycho kills, that sort of rather appropriate title of the red tops. We kind of assume that schizophrenia is linked to severe offending. And actually, although there is a little bit of truth in it, by far and away, the other majority of people with severe mental illness are completely okay in terms of risk to others. They're not violent people. They're not monsters. They're not aggressive. They're not threatening. In fact, quite the opposite. Mostly they're a big risk to themselves. And I think that society, others, these people, and we kind of need the bogeyman. It's akin to the pedophile, the rapist, the child molester. And I fear that madness, which is what ultimately schizophrenia is, it's what it means. It's a classic form of madness. We've put mental illness in that rather unpleasant soup of perverse or abnormal human behaviors. And again, I think it's interesting your use of the word neurological conditions, because I do see them in those terms. I do see it as a very clearly medical disorder. There's another fascinating study looking at twins, which is often trotted out that I think it's highly important. If you have a pair of identical twins and the other person, one of the twins gets schizophrenia. The other twin has a 50% chance of getting schizophrenia as well. So the concordance rate is 50%. Now, being identical twins, if it was a purely genetic disease, then it should be 100%. If one gets it, both will get it by definition. So clearly, although it is massively genetic, we also know that there is some environmental or social influence that moderates the genetic expression. So it's not an invariable outcome, which actually provides hope for people as well. So it's one of these curious genetic disorders or medical illnesses that can be moderated. The sadness is the difficulty is we're not entirely sure what moderates it. And it's interesting that you mentioned about not everybody who has schizophrenia or these mental conditions will commit to crime or be violent. So you worked in a hospital and in a prison. What percentage of the prison population would you see in there, because I'm curious to find out, I thought a lot of the prison population would maybe have schizophrenia, bipolar, etc. But based on what you said about the crime rate and the not all committing crime, I could be wrong. I think if you go into any prison, any remand prison, because by the time you get down to where people often spend much longer periods, the dispersal units, it's a slightly different population. But if you go into a remand prison, you've got people off the streets, and probably I'm guessing 30 to 50% of them would have an identifiable psychiatric disorder. Now, only a proportion of those will be psychotic. The things that you see so much of, and probably a third of people going into prison have a severe dependency disorder, be it alcohol or substance use. But against that, you've got high rates of personality disorder, complex trauma, anxiety, depression. And then you'll have a group with drug psychosis, stress induced psychosis, or an underlying chronic, severe mental illness, like schizophrenia or bipolar. When you look at homicides statistics, I think it's been pretty consistent over the last 20 or 30 years. Only 10, 11% of people charged with murder will get a diminished responsibility finding, implying that there is some external factor that has mitigated the severity of their sense. I think that's fairly consistent, and because of the high tidy-up rate of murder in terms of people being caught, the overwhelming majority of murders are solved, thankfully. It's pretty robust statistics. I think then if you look at the hospital population, we're dealing with people who come in primarily now because of the mental illness, not because of offending. So it's a civil detention, or people are coming in informally. Again, that will bias the sample that we're looking at, and most people coming in these days will be psychotic, usually with relapsing psychotic disorders, sometimes first onset, sometimes bipolar, sometimes severe depression. The threshold for admission now is alarmingly high, and you have to pass that very demanding exacting bar, usually meaning that you end up coming in under a section of the mental health act. Those people are always going to be risk-assessed, but overwhelmingly people are not from an offending population background. Many might have offenses, but goodness only knows. I think about a third of adult men have a conviction, so it's hardly a discriminatory tool. When you said they're coming in under the mental health act, am I right in saying that the mental health act doesn't apply to your patients in prisons? If they refuse to take their medication, you can't make them, whereas if they're in a hospital, you can make them. If it was a life-saving issue, then you could use common law to treat them, you could use the Capacity Act, but any consistent, longer-term treatment approach, whether it's for psychiatric or medical issues, you would need to transfer somebody out of a prison. That's simply because they're not regarded as hospital facilities. The mental health act only applies to hospitals, designated hospitals, and health care centers in prisons are not hospitals by definition. I've long thought that that should be looked at carefully, so that we should be able to treat people cohesively in prisons, and the older I get, the more cynical I've become about how that could be abused. I think it was set up originally in the post-war world because of a fairly sophisticated liberal thinking approach that we don't want to treat people cohesively in the prison environment, that the state exercise of detaining people shouldn't apply to people with mental disorders. These days, because of financial pressures and the fact that prison is so much cheaper than medium or high-secure psychiatry facilities, I fear that people would simply see it as a cost-saving exercise, and people would then be treated cohesively in prisons without the full range of care and treatment they deserve a need. They wouldn't get the psychology, the OT, the nursing care, so we'd end up reducing the complex issue of treating people to forced injections or anti-psychotic drugs, and that would be wholly wrong. I think I've come full circle in my thinking. That's really, really fascinating. I was actually going to ask you what's the difference for a patient who you see in prison compared to the hospital, but they'll get so much more robust treatment in the hospital. But before we go on to the differences, if you want to expand on that, when they are in prison and they're not taking their medication, you're talking to a book about different patients where they're not taking their medication, and how they are behaving is very erratic. And then when they're taking their medication, they're like a completely different person. And my question is, if somebody's in prison and they're not taking their medication, is that then putting prison staff, other prisoners, people like yourself, and the prisoner themselves at much more risk of harm? Yes, all of the above, Kagan. It's so important to realize that when people are mentally old, they are simply not themselves. They're acting out of character. They might have actually committed the offense directly as a result of the mental disorder. In what we fear most, I wrote about a case I had where a chap, actually a well respected teacher, had been driving with a large samurai type sword in the boot of his car, and he would stop the speeding. And when the officer stopped him and said, "Look, what's going on? Why are you speeding?" He said, "Well, I'm off to kill the devil." And then gave an address as to where he was actually going to go to decapitate the person who was responsible for all of the sins in the world. So it was a fortunate, it was a fortunate speeding stop that stopped to homicide. And that was just good luck. But this chap, once he was treated for his bipolar mania, or possibly more accurately, a schizoaffective disorder, he actually was a perfectly reasonable, thoughtful individual. And I think that that's part of the skill of a forensic psychiatrist, is to differentiate between people who are doing acting out of character, or people who are committing serious offenses, who may or may not have some other psychiatric disorder, where it's probably not actually relevant to the commission of the offense. So you've got to sort of go back and look at the historical narrative, look at someone's personality structure, look at how other people see them. It's often important to get a third party information from friends, relatives, lovers, partners, and so forth. And then look at their offending history, their use of substances, how they committed the offense in what circumstance, and then think about a suitable disposal, whether it's a prison sentence, or a more nuanced approach with a hybrid treatment order, or putting somebody wholly into the psychiatric system. And how do you make that decision, because we don't need to go into the specifics of this case, or give your professional opinion, but it just got me thinking about this case. So the gentleman in Nottingham, who really unfortunately killed three people, he got a hospital order rather than imprisonment. And I remember there being public outrage about him getting a hospital order. It even went to be reviewed to make sure that that was the right decision that the judge made, and it was confirmed that it was. How did they decide whether somebody should belong in prison, or whether they should belong in hospital after they have committed crime? I think the person you're referring to is Kallaken. And I think without talking about that case specifically, what you have to do is look at somebody's medical and psychiatric history. If somebody has a schizophrenic illness, and we know that when they become unwell, they might be hallucinating, they might be hearing voices, might be racially abusing them, calling them a shit. They might be getting instructions from, for instance, the spirit world, or MI5. They might have microwave beams changing their behavior, controlling them as if they're a marionette. They might have the sense that their actions are being determined by some outside force. So you have this complex range of hallucinatory experiences and delusional experiences, which are very often paranoid and persecutory in nature. And then they might be self-medicating with alcohol or substances. They might have stopped taking the anti-psychotic drugs. And then there's a reasoning issue, a mental capacity to detach from their illness has changed. So they've lost insight and they're wholly invested now in their psychotic world, which must be like being in a living nightmare. And it's only at that point that they then become dangerous to others. Then I think it's fair and reasonable in a just society to say, well, they're not wholly responsible for their actions while they're unwell. So I do understand the public outrage. But I think when you dispassionately look at the individual case rather than going, we have to punish anybody who does anything bad and look for the reasons why they do it. You can actually have a much more sophisticated, thoughtful and ultimately liberal approach where you get the treatment or the punishment that you deserve. And in his case, quite clearly, when it was looked at that the outcome of a diminished responsibility finding was thought to be fair and just. So now hopefully he's getting the care and treatment that he needs. Make no mistake, it's not a holiday though. If you go off to a high secure hospital, you are going to be there probably after a homicide for an average of 10 or more years. Now, I think the last time I looked an average life sentence was probably in the region of 10 to 14. It depends what group of life sentence prisoners you look at, but it's in that sort of territory. So if somebody is then treated and if we can then release them into society as most people, the overwhelming number of people committing homicides are going to be released at some point. If that can be done safely at an appropriate time when they are safe and they will still be subject to a life license, which means they could be recalled at any stage, then actually I don't see a problem with it. And ultimately we have to move on from this sense of the need for personal justice because I don't think that is the hallmark of a civilized society. I completely agree. And I have a question then about the rehabilitation of people who have diminished responsibility or even people in prison who clearly have neurological conditions and they take the medication and they're much better. Obviously, if somebody doesn't have that, they're in prison, they're doing offending behavior programs, and they're maybe changing their thought process so that they don't commit crime in the future. But with the patient you see, it seems like whether or not they take the medication is the deciding factor about whether they go back and relapse and commit more crime. How do we then mitigate them committing crime again in the future if it's solely done to them deciding whether or not to take their medication because if they are taking the medication, a lot of them might think, well, I'm better, but it's actually only because they're taking the medication. So how do you get around that? Well, going back to our earlier commentary about most people with schizophrenia and not being offenders, I would disagree with part of the premise of your question now that it's not just the reductionist argument that medication is the key issue. Most people who happen to have schizophrenia and go on to kill will also have underlying traumas that might shape their personality structure. They might have an emotionally unstable or paranoid or the social personality disorder. And almost invariably they will have been through very adverse life experiences from inconsistent caregiving, split families, poor educational attainment. Often they're the victims of abuse, often sexual abuse, physical abuse, certainly emotional harms from their developmental periods, and they carry those issues with them into adult life. So difficult, dangerous kids become difficult, dangerous adults, by and large. And I think that the issue of treating the psychosis is just one aspect, and we can enforce the medication and it might suppress their symptoms, but what we're left with is a very difficult, challenging individual, often, not invariably. And they then need that rehabilitative experience where they can start to, as you've described it, understand what went wrong in their life, the group pressures they were under. They can start to look at the relapse indicators of their illness, in what circumstances they offend. They can get education, psychoeducation, reasoning and rehabilitation classes, offender management issues. And they're not then suddenly discharged from that process. The whole issue of discharge is one of a staged, phased reduction of the level of support around them. So that when they go out, it's not sort of they've had huge amounts of care one day and nothing the next. They move the whole process of deinstitutionalizing these people at the end of a lengthy hospital or custodial experience is usually one of slow progression into the community and safe stages. It doesn't always work, but by and large, I think it's a very well-worked system. Treating not just the mental illness with drugs, but also the whole person. So in that sense, it is a truly holistic approach. And I think that's to the credit of all the services that cooperate from probation, social services, psychology and medicine. Yeah. And you talk about the fact that it's preparing them to be able to go back out into society. And obviously, I'm not sure if this is the same in prison, with your patients in hospitals, you give them leave, go out into the community. And you talk in your book about a patient who kept not coming back and the police said, "Oh, him again." And you say, "Why do you keep letting him out?" And you said, "Well, we have to. He's entitled to be able to leave." Is there any backlash on you as a consultant when somebody goes out into the community and commits crying because you talk about a person who went out and unfortunately robbed a post office? Is there any backlash for you or because that is part of your duty to get them used to being in the community? Is it just kind of seen that it's a hazard of the job? I wish we could dismiss it as a hazard of the job. It happens. No, we are very much responsible. And therein lies a difficult clinical paradox. We, many years ago in the medium secure unit I was working in, were looking at our rates of abscontion from leave. And I think we identified a certain percentage. Let's call it 5% of people came back late or didn't come back. Now, if we are taking people who are no longer in prison, who are not subject to a custodial sentence at that point, they are receiving treatment for a mental disorder. And that's why we're with them. We have to practice along the least restrictive principle. So that whatever we do, we have to think, is this the least restrictive technique, process, treatment approach that allows them to receive the treatment they both need and maintains public safety. Now, when we are trying to then rehabilitate people back into the community, when going back to prisoners, long since disappeared as an option, it seems to me perfectly reasonable to take positive risks as they are euphemistically turned. Now, if somebody then comes along and says, well, I think 5% adverse outcome in terms of your risk taking is appalling. I think you should stop it. We could, we could simply stop all abscontions. All bad things happening. We just don't give anybody any leave ever. And the consequence of that is that people then not progress. They wouldn't leave the hospital environment and they would society would then have to double triple the numbers of medium secure beds over the nation at probably around £160, £170,000 per person per annum, which I guess is probably not something that society would like to do or enter into likely without some degree of thought or public debate. So it's one of those curious paradoxes. We are responsible for the outcomes of our decisions and I think psychiatrists, because of that very palpable threat, the stick to the head rather than the carrot, we are risk of us and we are very cautious. We are never complimented for a good outcome. The only time society looks at what we do closely with the microscope, judishly, in a review process is when something has gone badly wrong. So we never actually have the positive reward from doing our job well. All we see is the negative consequences from doing our job badly or in a substandard sort of way, or sometimes where you make perfectly legitimate decisions. But then the patient decides to do something wrong or nefarious or whatever it is. So that is a dilemma which is going to run and run. And I think society has to take a decision ultimately on the basis of how many people it wants to incarcerate in treatment environments and at what cost and for how long. And it's a very vexed question. We could stop people offending. You don't need psychiatry hospitals to do that. You just lock people up for very long periods and get right. It's hidden. It's out of view. It's not in the public environment. Problem solved. But I don't think that's a reasonable position to take and I would actively talk against it. Yeah, I completely agree with you because we're not fixing the problem. Locking people away until when the only way we then mitigate it is by locking them away until they die. And I completely agree. It does not make sense. And people, I think, believe that's what happens though. That's the problem that I've worked very closely sometime again with Jackie Cressati who is treating people in the community when they had been convicted of paedophilic offenses. And she was talking about this approach for people with a very common disorder, sadly, about treating them in the community. And there was a bunch of people in the TV audience who booed her off the stage because all they wanted was these people to be locked up forever. And the truth is they were never going to be. Their offending wasn't that serious in the great scheme of things if it was, and if it was paedophilic sexual offending, they probably would be in prison. These were people who we had to do as a society try and keep out of prison and stop them offending in the first place. So there is a desperate desire for vengeance when it comes to people with mental disorders with offending which is seen as aberrant in some way. I don't think we adopt the same position as a society to burglars, people charged with violent offenses which often are equally damaging to the victims. Yeah, and would you agree that your views towards some behaviours changed throughout your career too because you mentioned the quote in your book was, I always knew I would struggle to treat people who killed children, let alone treat them fairly. And then you share a bit in the book that really opened my eyes where you cleverly share this story about a woman who really sadly kills her child. And I believe takes her own life too. And it turns out that it was actually a colleague of yours, so they were a forensic psychiatrist as well. And it really opened my eyes because I didn't expect that and it just goes back to that what we were talking about earlier where unfortunately mental illness can really happen to anybody and it drives people to do things that they would never do if they were mentally well. Would you agree? I would. I mean, what you reference the two into linked stories in the book. And the first case is in the public domain and actually I went to the Royal College conference this year in Edinburgh and there was a discussion piece in one of the meetings about Daxia Emson, Dr. Daxia Emson, who was my colleague who had recently been appointed as a consultant psychiatrist and we'd worked fairly closely as junior doctors when we were all called together in such likes, so we knew each other reasonably well. And she had had a bipolar disorder with recurrent mania and she had started to become paranoid. She'd come off her medication in order to get pregnant because of the risks of some of the medication that she was taking in pregnancy. So it was a thought through planned reasoned decision. And in the postpartum environment when I think her daughter Freya was just a few months old, she covered herself and her baby with an accelerant set far to themselves and her baby died and she was then taken to hospital to a burns unit for treatment and died a few weeks later having not regained consciousness. And I think that bought some changes as a result of the inquiry and the fact that it was recognised that doctors very often slip through the gaps of treatment and probably we don't make the world's best patients ourselves, sadly. And we were revisiting this thinking 20 years or so later at the Edinburgh conference, what's changed and in truth, I could see it happening again. I'm not sure that things have changed so much. I could be confident in saying that the same issues, the same shortcomings wouldn't apply in the future. The other case which I write about was the difficulty of regaining insight and the patient I wrote about was when I treated. And she had smothered her infant daughter in the context of profound debilitating delusional belief she thought her child was imbibed with negative spirits and was responsible for all sorts of problems. Basically, she thought she was a Satan child. And in the context of that belief structure, she smothered her daughter and then tried to take her own life by jumping in front of a bus and lost a leg as a result of it. And I think that the issue there was that whenever she recovered, she started to regain insight into what had happened and why. And for her, the psychotic process, the illness that she had was actually quite comforting because her reasons for killing the child were explicable within the context of her delusional beliefs. And when we treated her, she couldn't cope with waking up to reality. It was like taking the red pill in the matrix quite literally and sort of waking up to find that you were in Dreamland. And this was too much for her to bear. And then in the course of treatment as she was recovering, she then tried to kill herself. And that was a difficult treatment approach. And I think it made me realize how difficult it can be and what we are asking our patients to do to become well. So I think that was very much looking at the social aspects of recovery and how difficult it can be when we regain insight. It's a tricky one. And it was a very powerful thing to write and a difficult chapter to write actually. Yeah, I bet it's one of the parts of the book that really stood out to me and I found that really interesting about that patient where she didn't want to become well because she could not bear to know what she did because it was then rational. It was no longer rational to her. And you mentioned about doctors not being great patients and you mentioned in the book about three of your colleagues unfortunately taking their lives to mental illness. And I've spoken to general practitioners about not in the podcast, but who have spoken to me about the fact that they struggle with their mental health and they feel like they can't open up about it as a doctor. As a forensic psychiatrist you've obviously seen very difficult things and you've heard very difficult things. How do you think it impacts your mental health as a forensic psychiatrist dealing with that because you say in the book that forensic psychiatrists cope and cope until they can no longer cope. Do you feel like forensic psychiatrists are able to chat to their loved ones about it or is it kind of like prison officers where you feel like your family will never understand and you don't want to put that on them. I think there is help out there if you want to get it as a doctor that the problem is the recognition and the willingness to get it. And I think that's the area that there is a shortfall. I think there are a number of non statutory and increasingly statutory services and I've done occupational health clinics where I've seen senior medical and management colleagues who have been affected by their work. And I think I probably didn't realize that going through my career I think it was just sort of get on with it sort of something of the old fashioned stiff up a lip approach and you know we're all in it together so let's not moan about it too much. I think it was only when I left psychiatry and I left forensic psychiatry moved back into general psychiatry I realized that the chronic trauma and the toll that working with people with difficult mental disorders and most specifically serious offending behaviors had had on me. And I suppose I first realized that when I installed a very expensive alarm system linked to the local police station back in the days you could do that sort of thing. Because of threat and risk to me you know when a patient says to you make no mistake I'm going to kill you and your family and your loved ones. It's something that it's difficult as a doctor because I didn't go into my profession to incarcerate people it's something difficult and something other. So I think we do talk about it I think it would be nice to see probably slightly more directive approach so that people should be going to reflective groups and having discussions not just a yearly appraisal where it's rather glib how you're doing is everything okay. Are you getting the support you might want or need. But again I coming back to your earlier point I'd always be worried how we would be regarded. And I think medicine is a conservative profession and I think that if trainee or consultant colleagues said this is affecting me terribly I'd be worried they'd be ostracized rather than bought into the fold. And even now I'm not sure to what extent people could openly talk about their personal angst their personal issues the stress of the job without it negatively affecting their promotion likelihood. Yeah, unfortunately I'm not surprised you said that because I think there are a number of professions where you would be ostracized lose your credibility if you open up about how to impact you which is really sad because you're a human being. And it makes sense that this stuff would impact you and when you mention about the security system there was a bit in your book where you say that a prisoner had carved Dr Ben cave Dr Ben cave all around his cell. And was it after that did your wife say to you I think we need to get security system. Well that was one of the issues where it became clear to me I was probably not doing a regular job the way most people conceive it now that was a person who had come into the prison environment in which I was working and I'd sent him off actually rather sadly towards the end of his sentence to a high secure hospital for treatment. And it was quite clear to me that his offending whilst it was significant severe and probably drug related in the early days he had then sort of segued into offending differently because of psychosis and that's why he needed treatment. And that was very threatening because there was no direct threat he simply carved or wrote my name probably several hundred times around the cell wall and it was a very nice prison officer that I was working with. He said Ben you need to come and see this and I remember going in and I was pull acts and then sat down in the patient's feces it was probably not the best experiences. It was a bit of a double whammy. How was your day at work. Threatened uncovered in the series. Yeah not great. Not what you'd be on the job description I'm sure. And what were the main differences then between being a forensic psychiatrist in a prison and being a forensic psychiatrist no hospital because when I think about a forensic psychiatrist I just think that you're going around each patient's bed having a chat with them and prescribing medication. But I know it's much more than that and I know that even outside of that you're giving evidence in court as an expert witness you're writing reports for the parole board about whether somebody should be released from prison. But what are the main differences in the roles between a hospital and a prison for you. Oh it's the environment completely fundamentally we're seeing the same people in different environments and the thing that obviously gets you into prison is the offending behavior and the thing that gets you into a hospital is the mental illness. But the two sometimes sadly aren't far from each other and so in a prison environment you'd be seeing people on the house blocks for regular reviews you would often work closely with community nurses who are working on an in reach system within the prison system. And you'd be working with forensic psychologists. You'd be working up people for the court sometimes for court reports and you'd be going this person is so unwell they need urgent treatment outside of the prison environment you'd be looking at patients with complex traumas, autism dependency disorders and prescribing people for simple depressions and trying to get them through the court system without hopefully killing themselves. So it's an incredibly varied role within the prison environment. I think in a hospital there is a little bit more of the having the patient come to and we tend not to sit on the end of the patient's bed, although sometimes their patients do refuse to come to us. But I think it's a more traditional hospital consultant role there where we work within complex multidisciplinary teams. And I think therein lies one of the issues I think that my book certainly bigs up the role of the other professional colleagues because we don't work in isolation from a very large team, highly skilled people, highly committed, highly motivated group of medical and non medical professionals. So I think that's probably one of the good aspects that is supportive coming back to how we keep each other sane and support each other through difficult times. And again I think that's possibly one of the things I wanted to point out that when doctors write books I think very often it's the non medical professions who are neglected and it's a process of rather egocentric behaviors. And I just wanted to remind my readership that actually it's a complex multidisciplinary approach and you couldn't do it without that. Yeah I can imagine. And how do you think being a forensic psychiatrist has changed your view of the world? In the early years, I probably had something of a crisis about the nature of humanity and what we could do to each other. I think as I've got older I realize that the overwhelming number of people are fundamentally good and decent and honest and kind and supportive. And I suppose I will be coming towards the latter stage of my career a far more optimistic about human nature than when I started which possibly is the other way around to most people. And many people get more cynical and more detached the older I get paradoxically although I think the problems in society haven't gone away. I actually perhaps am more selective now in terms of looking at the good in people. And I think so many people who have had very difficult developmental times in their life who come from the most difficult deprived backgrounds. They do well. They get on with life. They have resilience and fortitude that sometimes I've no idea where it comes from. And I think that we see a minority of people and it is a small minority so it shouldn't join us on a view of human nature too much. I end my career more of an optimist than ever before I think. Well, that's lovely because I agree. I think it's definitely the other way around for most people. So I think that's really lovely that you feel more optimistic about humanity. And how do you think your view of people in prison is shaped by the work you do because I feel like in society we have polarizing views where some people know that a lot of them were victims first and that a lot of them shouldn't be there and a lot of people feel compassion for them. And then we have the other side of humanity who wish the worst things possible on people in prison. Where do you sit because you've worked so closely with them and how is it shaped how you view them? I suppose I'd like to polarize what we do judicially. And my own feeling is that I think that we probably should punish serious offenders with significant prison sentences. And I think at the other end of the market where people are perhaps at the lower end of the food chain in terms of drug use or offending behaviors. We need to have a far more social based outcome. And I think for me, by the time people end up in prison, it's almost too late. And I think we need Head Start programs, we need educative programs. Instead of treating end stage cancer, we need to stop people smoking in the first place. And I think that that project, when it comes to offending behavior, starts at the age of two, three, four and five. Every teacher I've ever spoken to, when I interview people's relatives or people who have been formative in my patients' lives. And that is sometimes the teachers. They always say, "Yeah, I knew this kid was different or wasn't responding in the same way or they had to social traits or they would bite or be hostile to other kids." It's very unusual to see people who are properly psychopathic without clear evidence of that in the early developmental phases, the childhood nad lessons. And I think that's where the treatment approaches need to start. And the other aspect of that, aside from the social and cultural aspects, are the educative side of it. It troubles me that I don't think in this country I've visited an adult unit in forensic psychiatry that employs teachers. And I have found out more patients than I would care to think about functionally illiterate at the end of five, six years of inpatient care. Now, sometimes they're not receptive to being taught. But how do we reasonably expect patients to go out into a complex, ever increasingly complex society where you have to be computer literate to get on and get a job, pay bills, deal with the things that we all have to sort out in life? How can they do that if they're illiterate and don't know how to add up, can't do simple sums and can't write a basic letter and can't fill in a job application? We are condemning people to a life on benefits and a life of dependency on society. And I don't think that's right. And I think we could be doing so much more to head people off before they get into prison. And I think very often we know who the problem kids or kids of concern actually are. And I think in some way we need to shape their futures. But that's a multi-generational approach. And the sad thing is when governments come and go, I think we need to have a 20, 30, 40-year project rather than something that appeals to the voting public today, next week, next month, which is often what politics is reducing down to. Absolutely. It's interesting you mentioned about people at school because I went to school with a boy who was, he was different. He would bully children. He was, I was very scared of him. He was quite aggressive. And he unfortunately went to prison. He could still be in prison for a very violent offense against a child. And as you say, it does start. I don't know what support he had at school, but I'm just saying it's an example where he was a young boy at that time and went on to commit violent crime. And as you say, we need to help them when they're younger and help the children because I agree that by the time they get to prison, it's far too late by that point. So we need to be focusing on a holistic life approach rather than just looking at building more prisons and what's happening by the time they get there. And I just want to mention this because I think it's really important when you were talking about drugs earlier, you said something in your book that I've never heard before. And I thought it was really brilliant actually. And when you hear it first time, you might think, "Oh, that's unusual." But I think it works where you said that people who have heroin addiction, we should give them heroin because that way they're not hurting people. They're not stealing from people. They're not creating crime and havoc in society to try and get their fix. If we actually give them it, they're not susceptible to HIV because they're using clean needles and it would actually create a safer society. And I thought it was really brilliant. I've never heard anybody say that before, but I think it really would. If somebody's already a heroin addict, I think it really would create a safer society because you talk about people being harmed. You mentioned somebody getting PTSD because six months prior, they were robbed by somebody to fund their addiction. And I just wanted to mention it on the podcast for people to think about because I thought it was really actually brilliant. You mentioning that in the book. Well, it's nice of you to say, Kagan, when I was working in the drug dependency world, I saw a lot of stable addicts and they were on methadone. And the ones who didn't use on top, the ones who didn't abuse the system, they did very well. And it strikes me that so much of the prison population, particularly in people's late teens and 20s, is drug related. And most people, I think, don't become heroin addicts. I see the other drugs like cannabis and LSD, speed, ecstasy, cocaine. They're all part of a complex problem that shapes the pattern of people's offending. But when you have got a drug that you could take relatively safely, if we could actually acknowledge that we're not going to create dependency and change society fundamentally as a result of supplying people like that with a safe, secure, clean supply of drugs. Why not? And I think we need more research looking at that have been little pockets of research with variable outcomes. But I suppose I would like to see, again, it's polarizing in this year, I'd like to see a more permissive approach for a small minority of people. So you would have to demonstrate that you have a dependency disorder. I think that could be then medically defined and you could then sanction treatment. And I think it would be a very thoughtful way of doing it. In a way, I think that many societal groups are going down the same process at the moment with cannabis. And again, I think it's probably too early to say how that's going to go. The question is whether we will actually by introducing a new drug, create new people with dependency. And I think with cannabis, I think people will start to say, goodness, cannabis dependency is a very clear thing. Doctors have known this for a long time, but I think society will wake up to cannabis dependency syndrome. And also, I think I'm cautious about cannabis, particularly because it is psychoactive, especially with the amount of cannabinoids in modern cultivars. I think it's any matter of time before we say, actually, these people are becoming profoundly psychotic when they're taking skunk or whatever varietal they're choosing. And I'm kind of worried it will actually impact very negatively on the ability of community psychiatry services to cope. Wow, that's fascinating. And my final question is, because, as you said, forensic psychiatrists, they aren't really thanked for the work they do. It's only when something goes wrong that we become aware of them. What's one thing that you'd like to leave listeners with, one positive thing about forensic psychiatrists that they might not know. I have no idea. We're not all like Hannibal Lecter. Good enough for me. Thank you so much for speaking with me, Ben. It's such a pleasure. I thoroughly encourage the listeners to read your book, What We For Your Most. It's a link in the show notes to it because it is fascinating. It's a fascinating insight to being a forensic psychiatrist, not only in prison, but also in hospitals. And I think it just gives the public much more awareness about these people because I learned so much from it. And it really opened me up to a lot of the misconceptions I had. So it was a really important read. So thank you so much for sharing your wisdom with us. Thank you, Kagan. It's been a pleasure to talk to you. I really hope you enjoyed this conversation. If you want to listen to monthly bonus episodes, you can subscribe for only £3 per month by hitting the link in the show notes. And I'd be so grateful if you'd quickly read the podcast on whatever platform you listen. It only takes a second and it helps more people to discover the show. [MUSIC PLAYING] [MUSIC ENDS] You
