Mentally Disordered Offender

Healthcare delivery for mentally disordered offenders (MDO) in Medium secure Services (MSU) It is a requirement from the government policies that wherever possible, mentally disordered offenders (MDO), must receive a comprehensive programme of care and treatment that is tailored to their specific individual needs (Wilson, 2004).The National service framework for mental health (DH,1999), requires healthcare services provided for MDOs to match those available for the general public.
MDOs are vulnerable individuals with serious mental health problems, who may have been engaged in some form of criminal deviance and cause danger to the public (McCann et; al, 2003). Treatment and interventions provided to this individual group should aim to alleviate symptoms of their mental health problems, increase quality of life and reduce the risk of recidivism (Humphreys,2000). However, all professional working with MDOs should have good knowledge base and understanding of the link between mental health problems and their offending behavior in order to provide effective interventions that aim to rehabilitate this client group(Dale, 2001) .

This assignment aim to discuss an aspect of health service provision for mentally disordered offenders (MDO) focusing mainly, on service provision for adult MDOs in medium secure unit (MSU). The author’s rationale for choosing this aspect is because she worked in Male MSU for MDO in a private hospital. While working there she developed some knowledge and understanding of the importance of mental health policy and criminal justice system. The Mental Health Act (1983) sections make the provision of care for MDO and their transfer from criminal justice system to hospitals for admission and treatment (2000). The author also realised the importance of communication among the multi-disciplinary team and some of the legal and ethical issues arises in relation to the provision of health care for MDOs such as, confidentiality and the restriction of liberty due to security and safety measures. Sharing of information can at times compromise the issue of confidentiality, if in the case of patients’ behaviour being dangerous or risk to others, confidentiality is often breached in terms of protecting others but, decision of breaching of information will need justification.

Within this essay, the author will start by defining MDO and discuss the nature and causes of offending behaviour and prevalence. Secondly Medium secure unit (MSU) will be discussed, that is looking at what they are/they do, their background when they were developed and evaluate the effectiveness of the services they provide. Third section will discuss the diversion process of MDOs from criminal justice to hospitals. Lastly the author will discuss interventions/ treatment options available within a MSU for the management MDOs and the effectiveness of these interventions then finalise with the conclusion.

Mental disorder has been described as the disability of mentally disordered offender” is referred to an individual with mental illness, whose mental illness is linked to their criminal behaviour and may have been in contact with criminal justice system (Prior ,2007) .mind (Department of health (DH), 2008),and “
Various types of offences maybe committed by MDOs, but these may vary greatly from minor to severe offence ( Humphreys, 2000). Sexual offences, violence/ antisocial behaviour, burglary, robbery, arson and criminal damage are some type of crimes found to have been committed by those in offender healthcare settings but, Sexual offences and Violence are most commonly crimes found to have been commited by half of MDO patients detained in forensic setting ( Duggan & Rutherfold,2008).

The actual cause of offending behaviour among mentally disordered people is not known, however evidence suggest that there is a link between mental health problems and criminal behaviour (Hagell & Dowling, 1999 and Woodward et al, 1999). Furthermore, studies by Angermeyer (2000), Arsenault et al (2000) and Walsh et al (2001) showed that there is a correlation between having Schizophrenia and increased rates of violence and antisocial behaviour. Evidence by Swanson et, al (2006) and Wallace et al, (2004) confirmed high levels of violent offending behaviour among people with schizophrenia and states that schizophrenic patients misuse substances and substance misuse is a contributory factor to increased risk of violence( Davison,2005). However, some authors suggest that the offending behaviour in MDOs is not only influenced by their active symptoms, but is also mediated by factors such as personality, vulnerabilities, social dislocation and coexisting substance misuse (Humphrey,2006).
The Social Exclusion Unit ( 2002) also identified some Key factors as influencing offending and re-offending behaviour and these are : education, employment, drug and alcohol misuse, mental health, physical health, attitudes and self control and institutionalisation ,family networks and financial support.The prevalence of offending behaviour is high in teenage years, and the onset of offending behaviour at an early stage in young people increases risk of long criminal career (Fisher et al (1993). Evidence also suggest that, gender, age, past violence and socioeconomic status have much greater effect on risk of violence than the presence of mental disorder.

Care delivery for MDOs is provided within a broad range of specialist forensic mental healthcare services such as; community services, prisons services, high secure hospitals, medium and low secure units also known as intensive care unit (Mason et al 2003).The level of risk posed by an individual will dictate level of security within which they are cared for (Callaghan &Waldock,2007). However, for the purpose of this assignment, the author will only discuss care service delivery within a Medium secure unit (MSU) which is also known as regional secure units.

MSU are special secure services designed to provide services such as assessments, treatment and a level of security for offenders with mental health problems, who are at risk of offending/ or present a significant danger to self or the public ( Benal et al, 2008). They also provide the same service to people with mental health problems who have never been involved with the criminal justice system, if they present significant danger to self/ others and cannot be safely managed elsewhere (Callaghan and Waldock,2007).
According to Jacques et al (2010), MSUs were developed in England and Wales following the Butler report in 1975 (Department of health & Social Security, 1975). The Butler’s committee reviewed the increasing problems on service provision for MDOs whose treatment were refused due to their dangerous behaviour to manage and due to lack of appropriate facilities. The Butler report(Home office & DHSS,1975) recognised the need for an additional level of security between high security hospitals and local psychiatric hospitals and recommended the provision of 2000 Medium secure beds for MDOs in England and Wales (Coid,2001). The Department of Health together with the Social Security encouraged the regional health authorities to provide medium secure units ( Coid et al,2001) However, the Department of health and social security ended up funding for the scheme as regional health authorities were taking their time and spending government funds on other services. Medium secure units were then developed and designed as intensive rehabilitation units, restricting patient’s admission with a time frame in mind for treating patients and their target length of patient stay in the unit for treatment was originally between 18 months to two years (Davies & Oldfield,2009). However, some patients are still assessed to require long term treatments and are staying longer in this environment due their different needs such as levels of treatment resistance, co-morbidity and institutionalisation (Jacques et al, 2010). Approximately one in three of patients assessed for Medium secure care in UK are thought to need long term treatment and 13% to 36% of those presently admitted have long term care needs greater than 5 years (Meltzer et al ,2004). The NHS Plan (DH,2000), indentified the need for more 500 long stay medium secure beds to accommodate those patients with long term needs (Davies &Oldfield, 2009). In 1990s mentally disordered patients who no longer require level of physical security in high secure hospital were still found to be cared for in high secure environments due of lack of appropriate facilities which also lead to the NHS plan (2000). Medium secure services have expanded over the years and there are approximately 4000 medium secure beds in England and Wales with about half provided in NHS and half provided by Private sectors (Duggan & Rutherford ,2008).In England and Wales, MSUs provide services to meet specific needs for individuals with learning disability, mental illness and those with personality disorders who require services under a this environment. They detain people with mental problems who are difficult to manage at lower level of security and who does not warrant detention in high security settings (Dolan et al, 2008), and patients detained under the Mental Health Act (MHA,1983). Medium secure units are a central point for the provision of forensic services to the community and criminal justice services. They provide more than just an inpatient services for MDOs, because they focus on therapeutic programmes linked to community resources ( Dolan et al ,2008). They are an important part of integrated pathway and offers assessments, treatment and rehabilitation as part of the discharge plan to MDO patients. The main aim of MSU is to address patients’ mental health needs, reduce the likelihood and potential severity of future behavioural risk ,while promoting the recovery (Davies et al, 2009). Despite the common goal, the effectiveness of service delivery varies between areas of England due to the availability of resources and funding (Coid et al,2001). Regions with more resources may provide wider range of services compared to those with fewer resources. Gault et al (2003), indicated that the location of patients before their admission has an impact on provision of services. The effectiveness of services in the treatment setting may also be affected by different factors such as legal status, cultural issues, gender, age ,diagnosis, nature of offence and antisocial behaviour, level of security required and length of stay (Lelliot et al,2003). NHS and Private medium secure hospitals have different form of service funding therefore, factors such as referral source and section under which individuals are detained varies between them. However, the effectiveness of medium secure unit at the author’s placement area is that, they maintain medium effective level of security and safety measures /policies in place to ensure safe environment for patients, staff and members of the public. They have locked doors and offer close observations to high risk patients to protect them from escaping or causing danger to self or the others.

Mentally disorder offender patients are usually transferred and detained in medium secure unit under the Mental Health Act (1983), through the diversion process. The term diversion is used to describe the range of assessments and liaison services in police stations, prisons, courts for mentally disordered offenders (Chaloner& Coffey, 2001). Diversion is a process of decision making resulting in MDOs being transferred away from criminal justice system to an appropriate health care services environment where patient get appropriate care and treatment (James , 2010). The process of diversion involves multi- agency working of different disciplines and requires effective liaison and collaborative working among them to ensure success, putting into consideration ethical and legal dilemmas that often arises when making decisions, regarding individual rights and an element of the risk to the general public (McClelland et al, 2001). The importance of diversion approach is that it identifies offenders with mental health problems (Riodan & Wix, 2000) and reduces the period of custody between arrest and hospital based treatment (Hamilton& James,1992). However, there a certain barriers that are found to hinder the effectiveness of the process and some of these are the unavailability of beds in secure hospitals, the nature of offence committed by an individual and funding issues (Denver et al,2006). Transferring of patients from prison to a secure hospital is still taking forever due to these factors (Soothill et al (2008).
The Diversion of patients from criminal justice system to a secure hospital occurs at any point (Humphreys,2006). MDO patients can be transferred to medium secure unit for admission and treatment from different areas such as the courts, prisons units and high secure hospitals. The following sections are used when detaining MDO patients under the mental health act 1983. Section 136 gives the police right to remove mentally disorder individuals from a public area to an area of safety for a mental health assessment as an option to arrest and prosecution (Soothill, 2008). If the outcome of the assessment requires an admission to hospital for further assessments or treatment ,patients may be admitted in hospital under sections ,2 ,3 , 35 or 36 of the mental health act (1983) depending with their legal status. Section 35 of the mental health act is the power to remand a mentally accused person to a hospital for a report on his mental condition and section 36 is remand to hospital for a psychiatric treatment to reduce the symptoms of their illness, (Soothill et al, 2008). Section 37 of the Mental Health act (MHA,1983 amended,2007), is a hospital order made by the court and section 41 allows the court to impose a restriction order on an offender when it is necessary (Humphreys et al 2006). A MDO prisoner who is serving a prison sentence can be transferred to a medium secure hospitals under section 47 and restriction order may be imposed by the home office under section 49 of the Mental Health Act 1983 (Humphreys et al, 2006). The transfer is made by the home office secretary, on receipt of two medical recommendations. Restriction orders are imposed to prevent serious harm that may be posed by MDOs to self or the public ( Denvir et al,2006). Other prisoners can be transferred under section 48.
At the author’s placement area, most the patients were detained under section 3, 37/41. The mental health Act 1983 (DH,2007),works well for diverting MDO patients to appropriate places ,however collaborative working among agency is a key to the effectiveness of the whole process. Main emphasis of the Bradley report (2009) is that all services at all levels of the system should be co-ordinated and integrated (James, 2010). Various treatment options and interventions are provided in MSUs that aim to reduce patients’ distress associated with their mental health problems, exposure to risk situations /dangerousness and offending behaviour (Humphreys, 2006).Specialist multi disciplinary treatment teams such as, Consultant psychologist, occupational therapist, nurses and social workers usually deliver interventions that are modified to meet specific individual needs (Callaghan & Waldock,2008). At the author‘s practice placement area, nursing interventions begins by carrying out a Multidisciplinary comprehensive assessment that identify patients’ history, needs, level of risk, and capacity to comply with treatment then treatment plan will be implemented in place. Risk assessment and treatment of patient are paramount of concern in medium secure unit and it is a shared responsibility among effective multidisciplinary team (Mullen, 2006). Pharmacotherapy, psychosocial interventions and Cognitive behavioural therapy (CBT) psychotherapeutic based approaches are interventions that are mostly delivered in MSUs and therapies such as anger management are offered in groups or as an individual therapy aim to modify some forms of difficult behaviour. Group therapy is the mainstay of most treatment in security setting because it maximise the use of resources and can be more effective and safe than individual therapy (Dale et al, 2003). However, the effectiveness of these interventions depends with the offender’s willingness to engage in therapeutic activities or comply with the therapy (Gilluley et) al, 2010). Some male patients are difficult to engage in therapeutic activities (Kettles et al, (2002). Also therapeutic relationship between the patient the therapist can affect the effectiveness of the interventions provided (,Davies & Oldfield,2009). In conclusion, the essay gave the definition of MDO, looked at the offending behaviour and its relation to mental health problems. Medium secure units were discussed, looking at how there were developed, their purpose , services and interventions they provide and the effectiveness of their services for MDO. The diversion process was also discussed, looking at how MDOs get transferred from various areas to a medium secure unit and the importance of multi- agency working. However the author decide to make some future recommendations which are to provide more extra medium secure beds because there is still high prevalence of mental disordered people who are wrongly placed in prisons due to pressure of beds ( Kettles et al,2003). Although, there is a recommendation from the Bradley report( 2009) that it should take a minimum of fourteen days to transfer a MDO patient from prison to a hospital, the effectiveness can still be affected where there is lack of beds. More funding is required. Lastly multidisciplinary working is the most effective and efficient method of providing appropriate treatment care for MDO patient in Medium secure environment. It also is important that nursing professionals keep enhancing their professional knowledge to ensure effective treatment for MDOs (Woods et al,2003). References:
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References: Bernal.J. Hall. I., Yacoub.E (2008) Secure in patient Services for people with learning Disability: Is the market serving the user well. Psychiatric bulletin 32, 205-207 with learning Disability: Is the market serving the user well Chaloner. C., Coffey. M ( 2000) Forencis Mental Health Nursing : Current Approaches. Blackwell science. Cohen A., Eastman N (2000) Needs Assessments for Mentally Disordered Offenders: Measurement of Ability to benefit’ and Outcome Coid. J., Kahtan. N., Gault.S. Cook, a (2001) Medium Secure Forensic Psychiatric Service: Comparison of seven English Health regions.. British Journal of Psychiatry 178, 55-61. Dale L. Thompson, T., Woods. P (2001) Forensic Mental health; Issues in Practice. Baillie’re Tindall Davies J., Oatfield Davison S.E (2005) The management of violence in General Psychiatry. Advances in Psychiatric Treatment.11, 362-370. Dressing. H., Salize H. J., Gordon H ( 2007) Legal Frameworks& Key Concept regulating Diversion and treatment of Mentally Disordered Offenders in European Union Member states. European Psychiatry 22 427- 432. Hewitt J.L. ( 2008) Dangerousness and Mental Health Policy. Journal of Psychaitric and Mental Health Nursing 15 ,186 -194. Humphreys M. (2000) Aspects of Basic management of Offenders with mental Disorders. Advances in Psychatric Treatment. 6 ,22-33. Isherwood S.,Parrott J (2002) Audit of Transfer under Mental Health Act from Prison Jacques J., Spencer. S. Gilluley P (2010) Long- term Care needs in male Medium security. British Journal of forensic Practice. 12 (3), 37-44. James D.V (2010) Diversion of Mentally Disordered Offenders from Criminal Justice System in England and Wales. Overview. International Journal of Law and Psychiatry.33 241-248 Kettles A, M., Woods Lelliot.P., Audini B.,Duffett R( 2003) Survey of Patients from inner London Health Authority in Medium secure Psychiatric Care. British Journal of Psychiatric Care.178, 62-67. Melzer D.,Tom B.D.M,. Brugha T( 2004) Access to medium secure Psychiatric Care in England and Wales.3: The clinical needs of assessed Patients .Journal of Forensic Psychiatry and Psychology. 15, 50- 65. Mercer D., Mason T., McKeown M., McCann G (2003) Forensic Mental Health Care. Elservier Science Limited. Mullen P.R (2006) Schizophrenia and Violence: From Correlations to Preventative strategies. Advances in Psychiatric Treatment. 12, 239-248. Prior M. P (2007) Mentally disordered offenders and the European Court of Human Rights. International Journal of Law and Psychiatry.30 546-557. Reed L, Lyne M (2000) in patient Care for Mentally ill People in Prison: Results of a year’s programme of semi structured inspections: British medical journal 320 1031-1035. Rutherford. M, Duggan. S (2007) Forensic Mental health Services: Facts and Figures on Current Provision. Sainsbury Centre for Mental health. Sales B., McKenzie N. (2007) Time to act on behalf of mentally disordered Offenders. British Journal of Nursing. 234 1222. Soothill K., Rogers P., Dolan M (2008) Handbook of Forensic mental health. Willan Publishing. Srinivas J., Denvir S.,Humphreys M ( 2006) The Home Office mental Health Unit. Advances in Psychiatric Treatment. 12, 450-461