Uncertainties surrounding the term ‘carer’ in policy and research were clear from the outset and have impacted on the study. In addition to carer, a range of other terms are commonly in use including ‘relative’, ‘unpaid carer’, and ‘informal carer’ (Scottish Government, 2010, p16), and more recently, ‘caregiver’ was the term used by the Scottish Recovery Network (Chandler, Bradstreet and Hayward, 2013).
More general uncertainties around the role of carer have been documented elsewhere (HM Government, 2010). For the group of carers under consideration, there are specific difficulties posed by common definitions of carer that make assumptions about residency, including that a carer is someone who helps a person to ‘remain at home’ (EPiC), or legal definitions that require an amount of care or eligibility for local authority services (Scottish Government, 2007).
It is worth emphasising that the recent service specification for high secure forensic services in England acknowledges that family and friends are carers, and supports the principles underpinning the Triangle of Care by the National Mental Health Development Unit (NMHDU).
It is also not easy to define ‘forensic mental health services’ as service boundaries are not always clear. For example, intensive psychiatric care units (IPCU) have locked wards and may care for a mix of inpatients using forensic mental health services and general mental health services. Services participating in the study were identified as forensic mental health services by the Forensic Network in line with its definition:
Forensic mental health services assess and treat mentally disordered offenders and patients with major behavioural, mental health problems and learning disabilities, in a range of secure health facilities and the community, in police stations, courts and prisons.
Forensic mental health services provide treatment and support to those assessed as at risk of offending, or who have offended as a consequence of a mental health problem, personality disorder or learning difficulties. It should be noted, however, that not all inpatients within forensic mental health services will have offended. Some will be cared for in a secure environment due to other risk factors, such as problem behaviours rather than purely on risk of offending.
Inpatient forensic services are delivered through a combination of low and medium secure hospitals and the high secure State Hospital. Community forensic mental health services are delivered through day centres and Community Mental Health Teams (CMHTs). However, some of those who are at risk of offending, or who have offended because of their mental health problems, will be supported and treated in general mental health services.
Our definition of a ‘forensic carer’ therefore was:
Someone of any age who provides unpaid support for a relative or friend who is using forensic mental health services, including those provided in low, medium and high secure and community settings.
Because of the long term nature of involvement with these services and the stigma surrounding them, this identity may be retained after their relative or friend has left hospital.