Management of offenders with mental disorder in specialist forensic mental health services

Pamela J. Taylor

Emma Dunn

Philosophy and theoretical models

Specialist forensic mental health (fmh) services are for people with serious mental disorders and grave offending behaviour who tend to be rejected from mainstream services. Although often triggered by single high profile cases, these specialist services are among the best planned and commissioned services in psychiatry, founded in evidence of need, risk and efficacy of interventions. They are grounded in a multidisciplinary clinical perspective and often have integrated academic units. They interface both with other clinical services and with the criminal justice service. Good relationships with the local community are vital for establishment and growth.

Mentally disordered offenders have been sources of tension between services at least since the early 19th century. In Britain, the Lunacy Commission argued that it was ‘highly objectionable’ that offender patients should be detained in a general lunatic hospital, while an 1807 parliamentary select committee noted that ‘to confine lunatics in a common Gaol is equally destructive of all possibility of the recovery of the insane and the comfort of other prisoners’.⁽¹⁾ High security hospitals followed about 50 years later.

Funding and commissioning of fmh services worldwide continue to follow oscillations between considered responses to changes in the structure and availability of general services, and responses to single notorious cases. For England and Wales, the Butler Report⁽²⁾ considered the then increasing gaps in service provision as psychiatric services shifted from mainly institutional to mainly community care. It was the most thoughtful and powerful driver of modern forensic mental health services in England and Wales, presaging the arrival of medium security hospital units. The contrasting path, of case driven service development, is illustrated by the so-called ‘Dangerous and Severe Personality Disorder’ (DSPD) services,⁽³⁾ driven by the inquiry into the care and treatment of Michael Stone⁽⁴⁾ following his conviction for two homicides and an attempted murder, occurring soon after his discharge from a psychiatric hospital. In the USA, mandated community mental health law (Kendra’s Law) and treatment programmes in New York followed a subway killing by a psychotic man,⁽⁵⁾ while legislative change necessary for specialist service development in Japan followed a school massacre.⁽⁶⁾ Concern that single cases make poor law – and poor health reforms—is tempered by the mutual commitment of government agencies and of practitioners to keep offender patient services under review.

The Department of Health and Home Office report, for England,⁽⁷⁾ is a good example of such review, proposing five principles for secure healthcare provision:

quality of care and proper attention to individual needs;
community rather than institutional care where possible;
security no greater than justified by the danger presented—to self or others;
maximization of rehabilitation and chances of sustaining an independent life in the longer term;
proximity to the patient’s own home or family if s/he has them.

It is arguable that only the fifth principle requires an evidence base. Intra-familial violence may contribute to mental health and/or behavioural difficulties, and most violence by people with mental illness occurs within their close social circle.⁽⁸⁾ Nevertheless, people have attachments, and the fifth principle is retained for that reason—and as a convenient way of anchoring responsibilities for services. The first four principles embody the medical ethic of maximizing autonomy and anticipated the Human Rights Act 1998, which gives effect to the rights under the European Convention to liberty and security of person (article 5) and prohibits degrading treatment (article 3). The Act also emphasizes proportionally —if it is necessary to breach a right, that breach should not go further than necessary.

Organizational models often founder in a clash between the needs of service users and providers. The ideal is a fully integrated services in which service users move freely between forensic and general mental health services, according to need.⁽⁹⁾ General services, however, tend to have to focus on crisis management, and the greater the tensions between specialist and general services the greater the likelihood of ever-longer periods of residency in a physically secure hospital⁽¹⁰⁾ or default to parallel service delivery reasons for this include reduced availability of non-secure psychiatric beds, perverse incentives in funding in which those in highest security may be funded centrally with minimal local funding burden. Also government caution may dictate that once detained in medium or higher security, every individual must progress stepwise through lower levels of security before returning to the community. Evidence does not support the notion that this stepwise route reduces criminal recidivism,⁽¹⁰⁾ but it has led to the growth of additional tiers of specialist security provision, including ‘low security’ hospital units and forensic community mental health teams.

The international context

There is insufficient space to explore the international context in any detail. Laws on criminal responsibility, criminal justice and mental health vary between European countries⁽¹¹⁾ and elsewhere, but many underlying clinical principles are shared. Most countries acknowledge some association between mental disorder and offending behaviours, but there is variation in how this influences prosecution, fitness to plead and stand trial, the extent to which mentally disordered offenders may be regarded as wholly or partially without responsibility for a criminal act, and the extent to which they are treated in mainstream or specialist secure health services, or in prisons, albeit with some health service input.

Our international research group (SWANZDSAICS) drawn from culturally distinct jurisdictions across five continents (Sweden, Wales, the Australian state of Victoria, New Zealand, Denmark, the South African province of Western Cape, Japan, the Canadian province of Quebec, and Scotland) finds a shared therapeutic philosophy in managing offenders with psychosis, but struggles to be therapeutic with sex offenders or people with personality disorder.⁽¹²⁾ Other countries however, most notably the USA, seek to separate the business of psychiatry in the courts from any therapeutic endeavour with mentally disordered offenders.⁽¹³⁾

The nature of security

Secure psychiatric hospitals have two overarching aims: improving health and delivering safety for patients and others. In secure hospitals, patients’ autonomy is limited in a number of important ways: they may not be allowed to leave the hospital at all, may be confined to a particular area within the hospital, and/or treatment may be enforced. Although these restrictions are undoubtedly at least partly in the interests of the patients themselves, they are commonly also in the interests of others.

The elements of security

Security in a clinical setting is made up of four main elements: physical, procedural, and relational security, and treatment. Treatment, including (re)habilitation, becomes vital to safety and security whenever a clear pathway can be shown between a mental disorder and offending behaviour.

Physical security refers to the qualities of buildings: the nature of perimeter walls and internal structures and functions. High security requires at least one high and distinct perimeter wall or fence clear of the main hospital building. In medium-security, the walls of the building alone generally provide the main perimeter, with high fences only surrounding exercise areas which are not entirely within the main building. All specialist security hospitals provide for staff and visitor entry through an ‘airlock’, using independent locking systems, the external one generally controlled by dedicated security or administrative staff. Ideally, clinical staff contributing to building design, which should ensure good sightlines throughout, while allowing residents a sense of privacy. Each patient has his/her own room, and ideally holds a key to it (with a staff over-ride potential). This enhances his/her safety and sense of personal security, and also the safety of property. In high-security units, cameras may be used for continuous monitoring. The environment should be pleasant, enabling both patients and staff to feel comfortable; small frustrations often trigger violence.

Procedural security provides for a formal set of checks for factors thought to be associated with risk of harm by patients. This includes minimizing patient access to weapons, fire-setting materials, or potentially disinhibiting substances, and preventing absconding. In high security, any communication with the outside world may be monitored; at lower levels of security, such monitoring is determined case by case. Procedures should also guard against potential harm to each patient. Some measures used to prevent or control violence may have ‘side effects’. Time-out and seclusion may be necessary, but can be provocative and open to abuse. Physical restraint may sometimes be essential, but if done incorrectly or brutally may damage the possibility of a therapeutic relationship, physically harm or even kill the patient. In the UK, procedures for such measures are subject to guidance both from professional bodies⁽¹⁴⁾ and legislative Codes of Practice (e.g.⁽¹⁵⁾).

There is insufficient space to detail the extensive range of procedures for ensuring security, so a couple of examples—searching and screening of contacts—must suffice. Searches of the person and of the environment are conducted mainly to minimize access to drugs and weapons. The level of unit security dictates the nature, extent and frequency of searches. In English high security hospitals, no-one is trusted. Staff, professional visitors and social visitors are all searched on entry; many items—such as mobile/cell phones are forbidden anywhere in the hospital. Patients may be searched randomly, but also when moving between areas in the hospital or if there are particular grounds for suspecting they have secreted something that could become a weapon, or acquired drugs. At any security level, patient rooms and other areas may be searched— similarly, randomly or on specific grounds; in high security, patients’ possessions are routinely restricted in quantity to facilitate searching. For all such occasions, however, procedures incorporate measures which reflect concern for the individual being searched. Patients must be informed of searches (immediately beforehand if randomly timed) and invited to observe.

Screening of contact with visitors is multifaceted. Visitors may be enticed into aiding absconsion, or be irresponsible in their ‘gifts’ for the patient; apparently innocuous items may be fashioned into weapons, and they may be under pressure to bring drugs, perhaps disguised in food. There may also be risk of harm to visitors. Telephone calls, mail and personal visits may all be observed, but only in accordance with written procedures. Policies pertaining to visits will refer to classes of visits—for example visits by specific individuals who may threaten or be under threat, or by children, Such visits must be supervised by specifically trained staff.

Relational security skills are founded in therapeutic approaches and, with specific treatments, form the core of hospital security, clearly demarcating hospitals from prisons. It lies in extensive knowledge of each patient, accurate empathy and highly developed capacities for communicating and working in a clinical team. At best, it not only provides immediate safety and the milieu for change, but it may also facilitate lightening of physical and procedural securities. Effectiveness, however, is reliant on sufficient numbers of adequately trained staff.

Relational security may, however, create anxiety in hospital managers and their political masters, partly because it is more difficult to understand as security than locks and walls, but also due to the perception that its corruption is possible and difficult to predict. Over time, staff may be vulnerable to potentially counter-therapeutic change.⁽¹⁶⁾ Strategies to ensure maintenance of clinical integrity therefore include personal supervision and appraisal, peer review and audit of team- and hospital-wide practice. Access to psychodynamic psychotherapists is not only, or even primarily, for the patients, but also for the staff and the institution.⁽¹⁷⁾

Treatment as security targets the link between symptoms of mental disorder, most obvious for psychotic symptoms, and criminal or risky behaviour.⁽¹⁸⁾ In contrast to prisons, secure hospitals generally select residents for their treatability. It seems simple then—specific treatment with antipsychotic medication for people with psychosis should bring safety—but matters are rarely so straightforward. Multiple diagnoses are common: at least 25 per cent of offender patients with psychosis have personality disorders established before onset of their psychotic illness, and many abuse alcohol and/or other drugs at levels to qualify for a diagnosis.⁽¹⁸⁾ Over 25 years, an increasing proportion of English high security hospital patients were found to have substance misuse disorders,⁽¹⁸⁾ especially affecting the psychosis-personality disorder group. Substance misuse not fully meeting diagnostic criteria is also common. In the short term, specific treatment for psychosis combined with preventing access to substances of abuse can restore safety. For longer term success and safety, specific treatments aimed at substance misuse are best integrated as part of the overall treatment package,⁽¹⁹⁾ although this is still not common practice (e.g. UK,⁽²⁰⁾ and Sweden,⁽²¹⁾). This may partly explain the counterintuitive finding⁽²²⁾ that, in the UK at least, there is a preference for admitting people with ‘pure’ psychosis to medium security hospitals, even though substance misusing people with psychosis would be regarded as a higher risk group (e.g.⁽²³⁾).

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