More Supportive Environments
As highlighted in the literature (Ferriter and Huband, 2003; Hughes and Hughes 2000; McKeown and McCann, 1995), this study found that carers can experience stress as a result of the forbidding nature of visiting secure settings, and/or because of the emotionally tense nature of meeting with their relative under forensic mental health services. Several of the forensic carers we interviewed referred to ‘dreading visits’ and when a visit went badly, needing to take a break from visits in order to cope, although this can lead to feelings of guilt.
There is a clear case for focused support for carers around visits to assist them to make more rewarding contact with their relatives and also to build trust with staff. Consultants and managers have a pivotal role to play to ensure the right culture is created to support positive, open (non-defensive) relationships with carers.
Some carers identified unwelcoming and prison-like environments, coupled with poor staff engagement as contributing to the sense of dread at visiting their relative. Carers can be fearful of voicing concerns in case this ‘rocks the boat’; or might be poorly placed to advocate when feeling upset or under pressure at visiting times.
At least one survey respondent reported feeling ‘abused’ by the system, and in interviews, forensic carers reported being reticent to raise concerns if they thought this might impact on their relative’s treatment. There were others who reported positive experiences of being supported by staff when there had been conflict and difficult issues to resolve in the relationship with their relative.
A distinct lack of privacy and/or of decent facilities for patients and their relatives to share a ‘cup of tea’ – a sense of normality in a foreign environment – increased the gulf between carers and their relatives, negatively reinforcing the custodial rather than therapeutic element of forensic care and treatment.
In this respect, the visitors centre at the State Hospital appears to be a missed opportunity to enhance support to carers: visitors congregate at the visitors centre with access to refreshments, before being transported to the wards, but the only staff they meet at this time are security personnel and some carers felt that they should not speak to other visitors because of perceived confidentiality issues. There is an opportunity here to encourage and develop peer support as well as for staff engagement.
Throughout this study, the most unreserved criticism from carers centred on the State Hospital. However, there was ambivalence: it was clear for example, that some of the practices most welcomed by carers are offered at the State Hospital, and that some staff are committed to providing support to carers and implementing bespoke practices, such as published accounts of efforts to develop a range of psychosocial interventions (Walker, 2004; Walker and Connaughton, 2012).
High secure services such as the State Hospital also appear to be off-putting for carers because of public image and its reputation as a ‘prison rather than a hospital’, all of which are live concerns for progressive service managers and staff.
That said, it is clear from our findings that attempts were in progress to improve visiting arrangements for carers across forensic mental health services, which reflects national developments (Cormac et al, 2010), including major works modernising the built environment at the State Hospital and some development of carers centres at other sites.
The location of secure units, particularly of medium and high secure, within the Scottish geography creates practical challenges for carers wishing to remain in regular contact with their relative. In this regard, a commitment from key staff (including named nurses and consultant psychiatrists) to engage in telephone contact with carers had proven invaluable. In the wider literature, innovations in the deployment of digital technologies have been suggested as various solutions for communication issues in wider health care services, especially when distance and separation are at stake (MacInnes et al, 2013); for example, Absalom-Hornby and colleagues’ (2012) development of family intervention utilising web-cameras for secure settings. I
n our survey of services, however, minimal use of new technologies such as Skype or email were reported as being used to assist families to stay in contact. Such circumstances might reflect security restrictions on the use of digital technology by service users. As carers become more knowledgeable about possibilities this could raise questions about how patient access to technologies such as e-mail and mobile phones is regulated or supervised.
Particularly given the challenges of the Scottish geography, there might be room for more sophisticated appraisal of individual capabilities and risk in relation to such access, or supervised access, rather than relying on blanket restrictions that merely reflect the level of security of the unit as a whole.