Specialist forensic mental health services

Specialist forensic mental health services

SOPHIE DAVISON, South London and Maudsley NHS Trust, London, UK

Introduction

As forensic psychiatrists the majority of our work is therapeutic. Prisons are notsuitable places to treat people with serious mental disorders, as you will realize ifyou have visited one. Therefore we admit those who need inpatient treatmentto psychiatric units. The current Mental Health Act (1983) permits the transferor diversion of mentally disordered offenders from the criminal justice system tohospital at each stage of the legal process.

Patients in forensic psychiatric units are distinguished from those in generalmental health services by the risk of harm they pose to others. Our challenge isto support and maintain an environment that enhances the therapeuticrelationship as much as possible whilst keeping patients, staff and the publicsafe. We cannot provide effective treatment in an unsafe atmosphere but anunduly restrictive and coercive regime will also hamper attempts at therapy. Animportant general principle is that patients are treated in the least restrictivesetting in which their treatment needs may be met safely.

The nature of security

Within forensic mental healthcare units, security refers to the measures takento ensure that patients, staff and the public remain safe. Such securitycomprises several different components: relational, procedural and physical/environmental.

Relational security arises out of the therapeutic relationship between staff andpatients. The multidisciplinary team knows the patients very well and therebygains an understanding of the circumstances in which each individual presents arisk and to whom. The staff can detect changes in patients’ mental states and/orthe ward atmosphere that indicate increasing risk and will then take appropriateaction. They also provide an environment in which patients develop a trustingrelationship with the team and talk through their frustrations, exploring

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alternative ways of dealing with stressful situations. If patients do becomeaggressive then staff are expert in managing violence safely.

A related type of security is that provided by effective and appropriatetreatment of the patients’ psychiatric disorders. As part of this we encouragepatients to engage actively in their treatment programme and we monitor theircompliance.

Procedural security refers to the policies and practices that are in place withinunits which assess, minimize and manage patients’ risk. These include policieson: observation; searching; testing for drug use; access to potential weapons;visiting arrangements; correspondence and telephone calls; access to money;management of aggression; management of absconding; and leave from the unit.

Physical or environmental security refers to the structural features of the unit.Barriers such as perimeter fences or walls, double-air-lock doors and speciallydesigned windows may all hinder or prevent escape. The layout of units shouldmaximize the ability of staff to observe the whole ward. Technology such asCCTV cameras and alarm systems may also be used.

Staffing

In order to provide the necessary level of relational security, nurse to patientratios are higher in forensic than general psychiatric units (Kennedy, 2002).Effective and safe treatment requires adequate numbers of healthcare staff(including nurses, psychiatrists, psychologists, occupational therapists and socialworkers) not security guards or prison officers. Security in all its aspects is theresponsibility of the whole team but on a day-to-day basis the nurses take mostof the responsibility for much of the relational and procedural security.

High security hospitals

Broadmoor, Rampton and Ashworth are the three specialist forensic high securehospitals in England and Wales, accommodating between them about 1100patients. Carstairs provides similar services for Scotland and Northern Irelandand Dundrum for the Republic of Ireland.

These hospitals provide inpatient treatment for patients who present such arisk of serious harm to others that they would cause grave concern if managedelsewhere. Most patients have been convicted of offences involving seriousphysical or sexual violence or other dangerous offences such as arson (Jamiesonet al., 2000). A very small proportion, detained under civil sections of theMental Health Act, have not been convicted. Patients in this group, about aquarter of the total, have usually engaged in very violent or dangerous behaviourwithin a less secure healthcare setting. Most patients have been admitted fromprison, as a result of court proceedings, or have been transferred at some timeduring their sentence.

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All three high secure hospitals treat male patients. Only Rampton provideshigh secure treatment for patients with learning disability and it will soon be theonly such setting for women.

Just over half of patients (58%) in the high secure hospitals have a psychoticillness, usually schizophrenia, a quarter (26%) have a primary diagnosis ofpersonality disorder and 16% have a learning disability. About a quarter of thosewith psychosis also have a personality disorder (Taylor et al., 1998).

The hospitals provide a full range of therapeutic services including medicaltreatments, group and individual psychological therapies, psychotherapy,occupational therapy, education and recreation.

Physical and procedural security measures have recently been increased atthe high secure hospitals. Measures now in place include a double escape-proofperimeter wall; visitor and staff searches; visits only by appointment; monitoringof letters and phone calls out (except legal ones); monitoring of patients’financial affairs and no access to cash; escorting of patients and visitors; thesearching of patients and their rooms; and various procedural security measuresaround drug testing.

The median length of stay in high security is just over six years (Butwell etal., 2000), although there is considerable variation. Less than a quarter ofpatients are discharged directly to the community with most being transferred toless secure hospitals as part of a graded rehabilitation back towards thecommunity. About 12% return to prison.

Medium secure units

In the mid-1970s the government began to develop regional forensic psychiatricservices, principally by setting up medium secure units (MSUs or RSUs) with alevel of security in between general wards and the high secure hospitals. Thereare now many such units and the service is still rapidly expanding. The demandfor beds in the NHS has outstripped the number provided and the private sectorhas filled the gap with similar units. In 2000/2001 there were about 2200 NHSmedium secure beds in England and Wales.

About three-quarters of patients in medium secure units have a psychosis,most commonly schizophrenia. Between 10% and 20% have a primary diagnosisof personality disorder (Faulk and Taylor, 1986; Bullard and Bond, 1988; Coid etal., 2001). The average age is usually in the early thirties with a considerablerange from 18 to old age. The behaviours most commonly associated withadmission are violence to the person including homicide, threats of violenceand arson. About a third of patients are not admitted following conviction butcome from general psychiatric wards and the community because of theirbehaviour, including serious violence, threatened violence, fire setting andsexual misbehaviour (Coid et al., 2001). RSUs that service inner-city areas havean over-representation of ethnic minority patients, mainly of African Caribbean

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origin (Coid et al., 2000). Most patients are admitted from prison and the courtswith some coming from general psychiatric wards and about a tenth from thehigh secure hospitals (Faulk and Taylor, 1986; Bullard and Bond, 1988; Coid etal., 1991).

Many units were originally mixed sex with women greatly outnumbered bymen. Now most have become single sex, usually male, and specialist units arebeing developed for females. The characteristics of women needing secure carediffer from men. They are more likely to have a diagnosis of borderline person-ality disorder, a history of self-harm, and to have committed arson. There arealso plans to develop so-called ‘enhanced’ medium secure units for some women,primarily those who would previously have been treated in high securehospitals. There is a view that they need more relational and procedural securitythan conventional medium secure units offer but not the very high level ofperimeter security now present in the high secure hospitals. Specialist mediumsecure units for adolescents and for the learning disabled are also beingdeveloped.

Most RSUs have a secure exercise area bounded by a fence rather than ahigh wall. This will deter and delay escapes but is not designed to prevent adetermined escapee. Entry to the unit is through an electronic double-air-lockdoor that is constantly monitored and, within the unit, access to secure areas isthrough further locked doors. Ward areas are designed to maximize observationand the average nurse to patient ratio is about two to one (Kennedy, 2002).Only visitors on an agreed list may visit and visits are observed. Rooms areregularly searched. Patients are tested for drug use when there are clinicalgrounds to suspect use.

The full range of multidisciplinary treatments is available and there is muchflexibility as the needs of patients are very varied. Some patients who are acutelyunwell and pose a serious risk to others have to stay within the unit. Others,who are preparing for discharge and a return to community living, may leave theunit unescorted for part of the day to attend courses, work or day centres. Thustreatments not only focus on management of the acute phase but also onrehabilitation needs.

The units were originally designed for a maximum length of stay of 18months but some patients can stay considerably longer. Therefore a number ofunits are being developed for patients who need longer stays. Many patients aredischarged directly to the community, some return to prison and some, toodangerous to manage in medium security, move to one of the high securityhospitals.

Other forensic inpatient settings

A few areas have open forensic wards that treat patients who do not requirephysical security for the protection of others but who need specialist rehabili-

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tation to prepare them for life in the community. There are also an increasingnumber of low secure units. These are designed for patients who demonstratedisturbed behaviour in the context of a serious mental disorder and who requirea locked environment but not medium security. They usually need a period ofrehabilitation of up to two years. In most areas low secure wards are part ofgeneral psychiatric services and admit patients with challenging behaviour.

Community forensic psychiatry services

These have developed more recently consequent on the recognition thatspecialist risk assessment and management skills as well as knowledge of thecriminal justice system are necessary in the management of some mentally disor-dered offenders in the community. There has also been increasing concern onthe part of general psychiatric services and the public about the management ofrisk.

The exact model of forensic services in the community varies from area toarea (Buchanan, 2002). In some places they are integrated with the localcommunity mental health team (CMHT); in others they are completelyseparate. The team is usually led by a consultant forensic psychiatrist andcomprises nurses, social workers, and sometimes psychologists and occupationaltherapists.

The work of community forensic psychiatric services falls into two areas:

(1) Case management: They often manage patients who have been dischargedfrom secure settings, particularly those who present a severe and enduringrisk to others.

(2) Liaison, advice and assessment: They advise general psychiatric teams onpatients’ risk and on the management of that risk. They also often adviseand see referrals at a variety of local healthcare and criminal justice facilitiesincluding forensic mental health hostels, probation hostels, magistrates’courts, prisons and probation services. They also receive referrals for assess-ments from the local Multi-Agency Public Protection Panels (MAPPPS).These panels are set up by police and probation with a responsibility toprotect the public from dangerous offenders in the community.

References

Buchanan A (2002) Care of the Mentally Disordered Offender in the Community. Oxford: OxfordUniversity Press.

Bullard H, Bond M (1988) Secure units: why they are needed. Medicine, Science and the Law 29:329–332.

Butwell M, Jamieson E, Leese M, Taylor P (2000) Trends in special (high security) hospitals, 2:Residency and discharge episodes, 1986–1995. British Journal of Psychiatry 176: 260–265.


Coid J, Kahtan N, Gault S, Jarman B (2000) Ethnic differences in admission to secure forensicpsychiatry services. British Journal of Psychiatry 177: 241–247.

Coid J, Kahtan N, Gault S, Cook A, Jarman B (2001) Medium secure forensic psychiatry services.Comparison of seven health regions. British Journal of Psychiatry 178: 55–61.

Faulk M, Taylor JC (1986) Psychiatric interim regional secure unit: seven years’ experience.Medicine, Science and the Law, 26: 17–22.

Jamieson E, Butwell M, Taylor P, Leese M (2000) Trends in special (high security) hospitals.British Journal of Psychiatry 176: 253–259.

Kennedy HG (2002) Therapeutic uses of security: mapping forensic mental health services bystratifying risk. Advance in Psychiatric Treatment 8: 433–443.

Taylor PJ, Leese M, Williams D, Butwell M, Daly R, Larkin E (1998)Mental disorder andviolence: a special (high security) hospital study. British Journal of Psychiatry 172: 218–226.

Further reading

Snowden P (1995) Facilities and treatment. In Chiswick D, Cope R, eds. Seminarsin Practical Forensic Psychiatry. London: Gaskell.

Address correspondence to: Dr Sophie Davison, Consultant Forensic Psychiatrist,York Clinic, Guy’s Hospital, 47 Weston St, London SE1 3RR, UK. [email protected]

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Specialist forensic mental health services