Independent Forensic Mental Health Review: final report

1 Principles

Shared principles and aims can contribute to a cohesive culture within forensic mental health services that will support people to have a smooth journey through the system.  Two frameworks that the Review feels are particularly important in the context of forensic mental health services are those of the European Convention of Human Rights, encoded in the Human Rights Act 1998, and the Millan principles underpinning the Mental Health (Care and Treatment) (Scotland) Act 2003.  These frameworks are relevant to the care and treatment of all people with a mental disorder, but are particularly important in the context of forensic mental health services because the people in their care are subject to significant restrictions.  It is therefore integral that forensic mental health services are underpinned by principles that minimise unnecessary restrictions, reduce the adverse impact of the restrictions that are required and maximise people’s opportunities to move on from these restrictive environments.

1.1 Detention and people’s rights

People in forensic mental health services typically have a history of serious offending.  This means that, in addition to meeting people’s individual care and treatment needs, forensic mental health services must fulfil a public protection role by managing the risk of harm that they may pose to others.  As such, forensic inpatient care involves a deprivation of liberty and detention in a highly regulated and restrictive environment.  This means that people in forensic mental health services can experience significant reductions in their freedoms, autonomy and self-expression.

Adopting a human rights approach to the design and delivery of forensic mental health means establishing a standard of treatment that respects the dignity of all the people within the system.  The Human Rights Act 1998 incorporates the internationally recognised standards from the European Convention on Human Rights (ECHR) into domestic law.  Article 3 of the ECHR establishes a right to be free from torture or inhuman or degrading treatment or punishment.  This means that if people are detained then they must be in conditions compatible with respect for human dignity.  This includes receiving appropriate medical care and treatment if they have a mental disorder.  Article 5 of the ECHR enshrines people’s right to liberty and security.  This means that people cannot be detained without reason and that deprivations of liberty must not be arbitrary, disproportionate or unjustified.  It is permissible to detain mentally disordered offenders for treatment within forensic mental health services.  However, those services must guard against any infringements of people’s liberty that are not a necessary part of their care, treatment and risk management.  Article

Similarly, whilst the Mental Health (Care and Treatment) (Scotland) Act 2003 contains powers to place people under compulsory detention, it is also clear that such detention is only permissible if there is treatment available that might stop the person’s condition getting worse or that might lessen their symptoms and help them to manage them better.

Decision-making about people detained in forensic mental health services should follow the least restrictive option.  This is one of the Millan principles:

Service users should be provided with any necessary care, treatment and support both in the least invasive manner and in the least restrictive manner and environment compatible with the delivery of safe and effective care, taking account where appropriate of the safety of others.^[4]

The least restrictive option is especially important in forensic settings because of the length of time people can spend within these services.  Following this principle when making decisions about people’s care helps to minimise the impact of detention on their freedom, autonomy and self-expression.

1.2 Reciprocity, rehabilitation and recovery

Forensic mental health services must be underpinned by a principle of reciprocity.  Reciprocity is another of the Millan principles which states that:

Where society imposes an obligation on an individual to comply with a programme of treatment of care, it should impose a parallel obligation on the health and social care authorities to provide safe and appropriate services, including ongoing care following discharge from compulsion.^[5]

People within forensic mental health services are compelled to undergo treatment and subjected to substantial restrictions on their freedom.  The principle of reciprocity means that forensic mental health services must maximise each person’s opportunities to achieve and demonstrate recovery and rehabilitation in order that they may cease to be subject to compulsion and restrictions in the future.  It also means that when people have these requirements imposed upon them, then services must ensure that they are not subject to unnecessary restrictions or unduly delayed from moving on to conditions of lesser security.

The related goals of rehabilitation and recovery are important cornerstones in delivering a service which has reciprocity at its core.  Rehabilitative work can involve medication, therapy and training or skills development to help people to reduce the negative impact of their mental disorder.  In addition to treating symptoms, it also means working with the individual to reduce the risk they pose to themselves and others.  Successful rehabilitation should give people a sense of control over their life, hopes for the future and opportunities to build a ‘life beyond illness’.  As such, rehabilitation can help a person achieve ‘recovery’, where they can ‘pursue their own, unique, life goals in the presence or absence of continuing symptoms’.^[6]

Definitions of rehabilitation and recovery will depend upon the individual.  For some, it may mean treatment of symptoms and demonstration of reduced risk, thereby enabling social reintegration with fully independent living in the community.  For others it may mean adopting strategies to prevent further offending and supported living that maximises independence and agency in the context of ongoing risk management.

1.3 Person-centred practices

People in forensic mental health services should be treated with dignity and respect.  This means that they should be recognised as individuals and that the approach taken to their care, treatment and risk management should reflect a holistic multi-disciplinary assessment of their individual needs and risks.  As such, forensic mental health services should refrain from taking a ‘one size fits all’ approach to people at the same level of security, nor should they make decisions based on single elements of a person’s case, such as their index offence, in isolation from other factors.

Person-centred practice is central to the delivery of the principles outlined above.  For example, the least restrictive option for an individual will depend on their unique history of risks, progress in treatment, and presentation.  Similarly, rehabilitation activities must reflect individual strengths and weaknesses: whilst one person may need to develop confidence in life skills such as shopping, another might require opportunities to pursue further education or gain employment.  These practices need the support of a skilful and experienced workforce who are empowered to adopt a flexible and individualised approach in their work.

Ensuring that people have opportunities to participate in decision-making is a central element of person-centred practice.  Wherever possible, individuals should be involved in all aspects of their care.  They should be supported to participate in assessments and inform the development of their care plans, as well as being given choices about how they conduct their day-to-day life.  People should also have opportunities to participate in decision-making at service and system levels, for instance through involvement in the development of policies or the design and delivery of interventions.

None of these principles are new.  Together with the frameworks we have drawn from, they will be familiar to all professionals working in forensic mental health services.  They are highlighted here to underline the prominence they should have in the design and delivery of forensic mental health services and to offer readers insight into the thinking that underpinned the Review’s recommendations.