Forensic mental health services

• What are forensic mental health services?
• How are people referred to forensic mental health services?
• Liaison and diversion services
• Different types of forensic services
• Specialist staff
• Supporting families
• What happens when people leave forensic mental health services?

What are forensic mental health services?

Forensic mental health services are specialist services for people with mental health problems who have been arrested, who are on remand or who have been to court and found guilty of a crime. ‘Forensic’ means ‘pertaining to the law’.

These services are an alternative to prison for people who have mental health problems and offer specialist treatment and care. They are ‘secure’ units, which means that people who are referred there are not free to come and go. Most people are detained in secure forensic services under mental health legislation.

The time spent in forensic units depends on an individual’s recovery and progress towards rehabilitation. Professionals who work in forensic mental health services take decisions about length of stay in collaboration with the professionals who will be responsible for an individual's support and care following discharge. If someone has been found guilty of a violent offence, or has been considered to be dangerous, the Ministry of Justice and Parole Board are involved in decisions about discharge.

Not everyone who has mental health problems and comes into contact with the police or the courts will be referred to forensic services. Many people who have offended do get sent to prison. However, the government recognises prisons do not offer the best treatment and care to people with mental health problems, and is introducing services and training to make sure people are ‘diverted’ from the criminal justice system to forensic services as early as possible (see Liaison and diversion services below).

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How are people referred to forensic mental health services?

People with mental health problems can be transferred to forensic health services at the time of arrest, during court proceedings, or when they are in prison. They may be referred while they are on remand and waiting trial. A referral is usually made following an assessment of an individual’s needs, or a psychiatric report.

Under Section 37 of the Mental Health Act, a court can rule that someone convicted of an offence should be detained in hospital to receive treatment instead of being sent to prison. If the courts are concerned that an individual poses a risk to others, Section 41 allows a restriction order to be added to the Section 37. The Ministry of Justice closely monitors patients who are under restriction orders. They cannot be transferred to another hospital, or given leave, for example, or released without consent from the Ministry of Justice.

Section 47 of the Mental Health Act is used to transfer a convicted prisoner to hospital for treatment and Section 48 is used to transfer a prisoner on remand to forensic mental health services.

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Liaison and diversion services

Research has shown that prison is not the right place for people who have a severe mental illness. Being put in prison can make their mental health problem worse and increase the risk of self-harm and suicide.

This government supports (and previous governments have supported) a policy of ‘diversion’. The aim of diversion is to make sure people with mental health problems who have committed a crime have access to specialist assessment and treatment before they even get to court or have to spend time in custody – either after arrest, or on remand.

Lord Bradley’s Review of people with mental health problems or learning disabilities in the criminal justice system (2009) recommended the police and health services need to work together very closely.

He said all police stations and courts should have access to ‘liaison and diversion services’ to make sure people with mental health problems or learning disabilities who have offended are ‘diverted’ from the criminal justice system to more appropriate health services.

Liaison and diversion services, he said, can help make sure people are assessed properly; work to make sure that people with mental health problems who are arrested can be referred to forensic services rather than spending time in custody on remand; provide information to courts about people’s mental health problems; and make sure people who are arrested but not charged are referred to mental health services.

Liaison and diversion services do exist but the sort of service varies and they are not yet available everywhere. Lord Bradley recommended setting up a national system of liaison and diversion services by 2014 and the recommendation has now been adopted by the government.

The Ministry of Justice is working with the Department of Health and the Home Office to first pilot and then introduce liaison and diversion services in police custody suites and criminal courts within the timescale suggested by Lord Bradley. A National Liaison and Diversion Development Network now consists of 101 local liaison and diversion services. Part of the job of this Network is to pilot and determine the best way of running these services. 

Lord Bradley also recommended better mental health care in prisons and said there should be improvements in the process of transferring people with mental health problems (and people with learning disabilities) from prison into specialist forensic mental health units to make sure they get appropriate support.

No health without mental health, delivering better mental health outcomes for people of all ages (February 2011), the government’s mental health strategy, also emphasises the need for high quality liaison and diversion services in police custody suites and courts throughout the country. This document also pledges to introduce ways of ensuring prisoners who need specialist treatment are transferred quickly. It says criminal justice staff will be trained to help them refer people with mental health problems for assessment and/or treatment.

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Different types of forensic services

There are three levels of security within forensic units – high, medium and low.

There are three high secure hospitals – Ashworth, Broadmoor and Rampton. People referred to one of these hospitals are detained under mental health legislation because they are thought to pose a ‘grave and immediate danger to the public.’ Each of these hospitals is part of an NHS Trust.

Medium secure hospitals/units are for people who are detained under mental health legislation and pose a serious danger to the public. They are run by either the NHS or private healthcare organisations. There are special women-only medium secure forensic units.

Most people transferred from court or prison are sent to medium or high secure units initially.

Low secure units are run by either the NHS or private healthcare organisations. These are mostly used for patients detained under mental health legislation as an involuntary patient, or for people who have already spent time in a medium secure unit. Voluntary patients are sometimes admitted to low secure units.

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Specialist staff

Staff who work in forensic mental health services have special training that helps them offer appropriate treatment and support to people who have a mental health problem who have committed an offence. The treatment they offer focuses on an individual’s offending behaviour as well as their mental health problem. Specialist staff – including psychologists, psychiatrists, nurses, occupational therapists and social workers – work towards reducing the risk of re-offending, rehabilitation and recovery.

Staff who work in forensic services are trained in security and risk assessment, but they are first and foremost mental health professionals.

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Supporting families

Family members of people with mental health problems who have committed an offence may feel ashamed and stigmatised. The mental health professionals responsible for your relative’s treatment and care should be available to answer questions and offer family members support, or there may be a support group for family members available at individual units.

However, forensic services vary in the support they offer to family members.

A research project surveyed 68 medium and low secure forensic units in England and Wales and asked them about what sort of services they offered to family members. The survey asked about visiting arrangements for families and children, for example. Support was available in 63 per cent of the units, and three of them employed dedicated carer support workers. 40 per cent said they were planning to introduce support services for family members. The majority had visitors’ rooms and all but one unit had a policy governing visiting time for children. Just over a quarter had a carers’ support group, and just over a quarter offered family therapy for carers and families.

Most of the units were accessible by public transport. Nevertheless, people are often admitted to forensic services that are far from home and family members may have to travel long distances to see a relative.

There is advice for family members of people who are spending time in forensic units in a leaflet produced by the Partners in Care campaign (run by the Royal College of Psychiatrists and the (then) Princess Royal Trust for Carers [now part of Carers Trust]). This recommends regular contact with the specialist team responsible for your relative’s care. It also recommends finding out about visiting arrangements because they will vary between different forensic units. Visitors may have to book in advance and show identification, and there will be security checks.

You can get a copy of this leaflet by visiting the Royal College of Psychiatrists’ website.

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What happens when people leave forensic mental health services?

The mental health professionals responsible for people’s care and treatment will liaise with mental health teams who will be responsible for supporting an individual when they are discharged from forensic services. Many people who have been discharged from forensic mental health services will be eligible for free aftercare services under Section 117 of the Mental Health Act.

When people leave forensic services, it may be difficult at first to adjust to an independent life, particularly if someone has been on a secure unit for some years.

Various community-based services can offer support – generic mental health services, assertive outreach teams and specialist forensic teams, for example. People may be offered supported accommodation and help with finding employment.

A package of support will be discussed and arranged before an individual leaves forensic services. Family members should be should be consulted when plans are being made to discharge their relative from the care of a forensic unit.