Independent Forensic Mental Health Review: interim report

9 Who should be – and who is – in forensic services?

People expressed varying views about who should be on forensic wards, suggesting that the definition of 'forensic' is not clear cut. Some felt that the bar for accessing forensic services has been raised as a result of budget constraints, meaning some people who require specialist forensic care and treatment are not getting it. Others felt that bar has been lowered, with other services now expecting forensic services to accept people with non-forensic challenging behaviour and less serious offending histories. A 2017 Mental Welfare Commission report found that many of the people receiving care in medium or low security are there because they cannot be cared safely for in non-forensic (general) wards. About half the people receiving care in low secure were on mental health orders, not criminal orders, indicating two distinct groups of people receiving care.^[22]

People questioned the appropriateness of forensic mental health services for people with acquired brain injuries, cognitive executive dysfunction and diagnoses of personality disorder. They also recognised the lack of readily identifiable alternatives for these groups.

People talked about the ongoing use of forensic services to care for people who are unlikely to be able to progress to the community.

9.1 Acquired Brain Injury with offending or violence

There is no service in Scotland for people with acquired brain injury who exhibit offending or violent behaviours. People with such injuries and offending histories do not meet the mental illness criteria for forensic services and acquired brain injury units are reticent to take them due to their forensic history. When referrals are made, lack of bed availability on forensic wards means that people who are already in the forensic system are prioritised. However, it is also argued that forensic wards are not the right place for people with these injuries. While they may require conditions of security, it was argued they need neurological input rather than forensic. They may be transferred to specialist services in England.

One person with an acquired brain injury who spoke to the review said he did not want to be in the forensic ward. Other people who had shared wards with people with such injuries, while sympathetic to their situation, felt they took up too much staff time and that this affected the care that could be given to others.

9.2 Personality Disorders

A report by the Royal College of Psychiatrists in 2018 concluded that there is no clear evidence that a long-term hospital admission for the treatment of personality disorder helps to address the risk management issues associated with this diagnosis. Moreover, such an admission may be harmful by working against the long-term aim of developing skills to manage distress.^[23] Guidelines for admission to medium and high secure forensic services recommend that people with a primary diagnosis of personality disorder are not admitted. The criminal justice services is seen as the primary agency responsible for their risk assessment and containment.^[24] People pointed to the increased evidence base for treatment of personality disorder in the community using specialist psychological therapies. Given the high prevalence of personality disorders within the prison population, it was argued that this treatment should also be considered in prison settings.

Staff working in forensic mental health services do care for and treat people with personality disorder. This is because people in the forensic system often have a personality disorder but it is not their primary diagnosis. It was also reported that a small number of people with a primary diagnosis of personality disorder remain detained under the 'serious harm' test in section 193 of the Mental Health (Scotland) Act. The Forensic Network has made recommendations for minimum standards of staff training and support within services that manage or care for offenders who have a personality disorder. There was consensus among professionals that people with personality disorders require a different approach to treatment, formulation and risk management compared with people with psychotic illnesses. It was also acknowledged that treatment for personality disorders is resource intensive and takes time.

A number of NHS Boards have placed people with personality disorders out of area in independent low secure provision. The majority of these people are women and it can be difficult for these providers to move them to conditions of higher security. In these circumstances placements are sought in England. It can then be difficult to repatriate people.

It was said that forensic clinical psychologists can play a key role in supporting criminal justice colleagues involved in the MAPPA process by sharing risk management and rehabilitation expertise about people with personality disorders.

9.3 People who are unlikely to progress to the community

There are a small number of people whose risk is unlikely to ever be considered manageable in the community. These people are reported to be 'trapped' in medium and low services.

Many people saw the role of hospitals as progressing people. When people are not doing so, this can cause exasperation and impact on the therapeutic milieu of the ward. For example, one person complained that 'this is meant to be a rehab ward but some people have been here for 20 years'.

9.3.1 Progressive neurological diseases

The review was told that it can be difficult to rehabilitate people with forensic histories back into the community if they have or develop progressive neurological disease. As long as they present a risk of sexual or non-sexual violence, they will not be accepted into community nursing care. However, it was suggested that people with neurological conditions could be destabilised by living alongside those with mental illness. There was a call for specific resources to be developed for this group if they are to remain in the forensic system despite their conditions not being treatable.