"We don’t focus solely on disease – psychiatry is a holistic specialty, which also makes it enjoyable."
Dr Brad Hillier is a locum consultant forensic psychiatrist in an 18 bed male medium-secure ward, in the Shaftesbury Clinic, South-West London and St George’s Mental Health Trust.
When I was at school I was unsure which career to choose. As well as being interested in medicine I also had a passion for music and was offered a place to study piano at the Royal College of Music. I opted for medical school at the University of Oxford, and I’ve never regretted that decision.
During my degree we had the opportunity to spend a day at Broadmoor High Security Hospital. We were able to talk to patients and see how the hospital worked. I found it fascinating and the day helped dispel some of the myths I held about mentally ill offenders. It was this experience, coupled with encouragement from a tutor that helped me decide on a career in forensic psychiatry. After working as a junior doctor I embarked upon specialist training, initially in general adult psychiatry followed by forensic psychiatry.
I look after one ward of 18 medium-secure patients, who are generally with us for between two and four years. The ward provides secure treatment for offenders with severe mental health problems including schizophrenia, personality disorders and psychotic depression.
About 85% of our patients have committed a serious act of harm, such as grievous bodily harm, sexual offences, arson, murder or attempted murder and pose significant risk to the public. They also suffer from mental illness, which is why they are here in the clinic rather than in prison.
My day starts at 9 am with a ward round, where I review patients with our multidisciplinary team – this includes doctors in training, nurses, social workers and occupational therapists. I generally focus on our more unwell patients, who may be demonstrating physical and or verbal aggression. Once a fortnight I hold a more detailed ward round, and meet each patient individually. I also offer a day-time emergency on-call for four wards one day a week, and a night-time on-call 1 in 18.
Patients are often acutely unwell when they arrive on the ward. Initial assessments usually take 10-12 weeks. Treatment involves a combination of medication and psychotherapy. I also conduct in-depth risk assessments and ensure robust plans are in place to ensure the offending behaviour doesn’t reoccur.
I also work closely with our clinical psychologists and occupational therapists who provide individual and group therapies/activities. Monitoring the effectiveness of medication and therapy are important aspects of my job.
Each patient has a care plan and the aim is to move towards discharge into low secure accommodation such as a community forensic hostel.
As well as working on the wards I also visit prisons to undertake independent assessments for the courts and justice system. The job also involves lots of meetings - for new patient referrals, multidisciplinary discussions and clinical governance and audit matters.
My job also includes lots of contact with many outside agencies including the police, courts, social and probation services. I also supervise junior colleagues, conduct research and support other psychiatric colleagues.
It’s so rewarding to see people recover from the most fractured state of mental health. Changes can be subtle and take time, but they do happen. We don’t focus solely on disease – psychiatry is a holistic specialty, which also makes it enjoyable. I also love the complexity of the work and the opportunity to deal with so many different agencies.
The work can be stressful at times. Firstly there is the sheer volume of work. Then there is the stress of working with patients who present with harrowing histories and highly troubled backgrounds. As well as mental illness and offending behaviour, many also suffer from addiction to drugs and/or alcohol. Our patients have usually had the worst start in life imaginable, and then progress on a downward spiral. It’s important to find ways of coping and having the support of colleagues makes all the difference.
I’m often treating patients who are detailed under the Mental Health Act. As a doctor I want to do the best for my patients, but I must always remain mindful of the risks such patients present. You also need a robust personality in this job – patients might not like you and they are unlikely to show gratitude.
Maintaining a balance between work and life outside work is especially important in medicine, which can become all-consuming. I’m interested in the arts and I also play the piano.
I also see a psychotherapist each week, where I can discuss issues and feelings concerning work and my life in general. I also attend the gym at least twice a week. It is vital to find effective ways of relaxing in such a challenging job.
I’m hoping for a permanent position in forensic psychiatry, although jobs are limited and there is a lot of competition for posts. I’d also like to take some time out and work as a volunteer for a medical charity working overseas.
- it’s easy to get caught up in a treadmill – consider taking time out of training (or later in your career) to volunteer overseas
- find one or more mentors to support you