This review of the research and wider literature aims to highlight innovations and best practice in supporting informal carers caring for someone in forensic mental health services.
The scholarly literature includes different types of studies and some commentary, with variable quality of research as judged by the comparative prestige of journals in which this research is published. As such, the relative impact of this entire body of knowledge is likely to be limited. The research papers include a number of interesting surveys (including surveys of staff and relatives’ perspectives on services), qualitative analysis of carers’ accounts of their experiences, and some service evaluations. There are few experimental design projects and no trials comparing the efficacy of different initiatives and this is a significant gap in the literature. Some researchers have published several papers that cluster around particular studies or small programmes of research.
The UK has a more extensive published literature than other countries, with a certain amount of interest in Canada and Australia. In the UK, various broader developments have been influential in driving forward key initiatives. These include the advent of Care Programme Approach (CPA) as a means of organising case management, the impact of key public inquiries into failures of care in secure settings, notably the two focused on Ashworth High Secure Hospital, and interest in staff training and service models associated with psychosocial interventions (PSI). More latterly, the fashion for recovery-orientated services is having an impact within secure services and the implicit holistic framing offers an opening to consider more thoroughly the needs and involvement of carers (Allen, 2010; Drennan and Aldred, 2012; Chandler et al, 2013).
Needs of carers in a forensic context
A number of the studies have explicitly sought to define the needs, experiences or concerns of relatives associated with being a carer for a detained person or their interaction with services (McKeown and McCann, 1995; McCann et al, 1995; McCann et al, 1996; MacInnes and Watson, 2002; Ferriter and Huband, 2003) and there is one published literature review (Tsang et al, 2002). Other papers make mention of specific needs or difficulties in the course of reporting broader findings (McCann, 1993; Canning et al, 2009; Absalom et al, 2010; MacInnes et al, 2013). There are also commentaries which offer a view on carers’/relatives’ needs (McCann and McKeown, 1995), and at least one first person account from the perspective of carers (Hughes and Hughes, 2000).
The literature on provision of different forms of support for relatives recognises the various needs highlighted in the studies of carers’ needs and experiences and reports on attempts to address such needs. Taken together, these studies and commentary describe key issues for carers that include:
- The physical separation involved in visiting institutions at some distance from home, which can undermine levels of support and contact (McKeown and McCann, 1995; McCann et al, 1996; Canning et al, 2009; Absalom-Hornby et al, 2011a; 2011b).
- Increased stress or burden of care compared with carers of non-forensic service users, including fear of experiencing violence (McInnes and Watson, 2002; Tsang et al, 2002; Ferriter and Huband, 2003).
- Troubled family relationships can increase burden severity, with main problems being between the primary caregiver and other relatives (McInnes and Watson, 2002).
- Stress in their dealings with services, including the forbidding nature of security regimes (McKeown and McCann, 1995; McCann et al, 1996; Hughes and Hughes, 2000; Ferriter and Huband, 2003).
- Stress resulting from experiences relating to the actual index offence and treatment by the police or the courts, or anxieties associated with negative media coverage of forensic services; the latter might include fears of abuse from staff or other patients towards their relative (McKeown and McCann, 1995; McCann et al, 1996; Hughes and Hughes, 2000).
- The double stigma of mental health in the family along with offending, sometimes including hostility from neighbours or in the media (McKeown and McCann, 1995; McCann et al, 1996; Hughes and Hughes, 2000).
- Specialist and general information needs (McCann et al, 1996; Hughes and Hughes, 2000; McInnes and Watson, 2002; Canning et al, 2009; MacInnes et al, 2013), complicated by the use of confidentiality issues by services to effectively exclude relatives from information or involvement (Jubb and Shanley, 2002).
- Practical and emotional support needs (McCann, 1993; McCann et al, 1996; Hughes and Hughes, 2000; McInnes and Watson, 2002; Canning et al, 2009).
- Uncertainties around how to deal with their relative’s mental health problems (McKeown and McCann, 1995; McCann et al, 1996; Hughes and Hughes, 2000).
- Guilt and self-blame (Ferriter and Huband, 2003).
The latter point is also relevant to difficulties and challenges arising in the contact time between carers and the person they are visiting. As such, visiting times can become stressful and emotionally fraught encounters for everyone concerned (McCann et al, 1996). Carers of forensic service users also report more extreme perceptions of the burden of care, including fear of experiencing violence (MacInnes and Watson, 2002; Tsang et al, 2002) and certain commentators have argued that deinstitutionalisation policies increase the risk of carer victimisation (O’Brien, 1998). A Swedish paper makes similar points whilst stressing that parents in particular might be relatively unaware of the character of their son’s mental distress, confusing how they make sense of violent behaviour, possibly hampering relations with officialdom and services (Nordstrum et al, 2006).
Carers’ previous contacts with psychiatry can be disappointing or unhelpful (Hughes and Hughes, 2000; Nordstrom et al, 2006; MacInnes et al, 2013). Good practice in services concerns itself with involving relatives in discussion or decision making at key times, especially when discharge planning is at stake and there might be an option for seeking community accommodation near to the relative’s neighbourhood or at their home, or, indeed, ruling this out. A lack of involvement in such future planning can be a major cause of stress for relatives and feed into any anxieties for the future. The experience of carers across all mental health services has been that staff can be over-cautious in balancing service users’ right to privacy with carers’ rights to share in information (Gray et al, 2008; McInnes and Watson, 2002). In the secure context, Jubb and Shanley (2002) remark upon the extent to which confidentiality can be used as a reason for not involving families, sharing information, or even allowing access to ward areas, leaving relatives feeling excluded and isolated. Interestingly, this state of affairs was to some extent remedied in one secure unit using action research methods (Jubb and Shandley, 2002).
Szmukler and Holloway (2001) provide a persuasive rebuttal of the idea that confidentiality should be a catch-all rationale for not involving families. This does not have to mean that forensic patients’ rights to confidentiality are ignored (Kaul, 2001), rather that there is scope for attending to some important limitations on confidentiality while negotiating the practicalities and value of sharing information between all interested parties/stakeholders. Geelan and Nickford’s (1999) survey of use of family therapy in secure units did not identify confidentiality as a major staff concern, and associated this with the advent of the CPA possibly opening up possibilities for information sharing. The value of information sharing may not, however, be fully realised within services because of perceived complications such as confidentiality and a lack of appropriate local policy development to support best practice (Rapaport et al, 2006; Slade et al, 2007; Rowe, 2012). Slade and colleagues (2007) undertook a policy review combined with interviews with staff, patients and carers to derive a framework to guide information sharing in mental health settings. They recommend a distinction being made between general information and personal information that is new to the carer, with only the latter requiring consideration of confidentiality and consent to disclose, and emphasising good clinical judgement as pivotal in this process.
The first-hand account written by John and Clare Hughes (2000), parents of a young man admitted to a high secure hospital, though not recent, is a sobering read. As relatives they faced a series of stressful events and negative experiences, from the index offence, through the courts, to their son’s admission to forensic care. This included feeling somewhat excluded from contact with the care team in the initial stages, with their relationship with services confined by the imposition of a series of rules they should not transgress rather than any positive sense of what they could offer or what support they themselves might need. Eventually, with the advent of a relatives support group, these experiences became more positive, leading them to be strong advocates for such interventions and also to make the case for a positive charter of rights for relatives in such settings.
Assessment of carers’ needs is a logical consequence of accepting that they have needs separate from those of the person they care for, and services might attempt to address them. A specific assessment questionnaire for relatives’ needs in a forensic setting has been developed in the course of one of the psychosocially-orientated research projects: The Relative Assessment Interview Schizophrenia in a Secure Environment (RAISSE) (McKeown and McCann, 1995), itself based upon more general available assessment tools such as the Relative Assessment Interview (Tarrier et al, 1988). Arguably, other more general tools such as the Carers’ and Users’ Expectations of Services – Carers’ Version (Lelliot et al, 2003) could be adapted or utilised for forensic settings. The RAISSE focuses on relatives of patients diagnosed with psychosis, and as such is not necessarily applicable to all service users or carers. However, some of the issues or experiences of relatives will remain fairly common, as the tool, for instance, inquires into the relationship with the institution.
The literature makes a distinction between relatives/carers and professional staff caregivers. Staff views about meeting the needs of relatives are relatively under-researched. Absalom-Hornby and colleagues (2011b), for example, focus on psychosocial family interventions, and forensic staff identified barriers to such service developments and offer their views on how to overcome them. Five barriers are described which include constraints on staff time, lack of training, poor support for interested staff, problems around information sharing and limitations due to geographic distance. Seven solutions are discussed that include clear pathways for family intervention training, protected staff time for family work, effective family policies and service structures, appropriate supervision contracts, managerial support, education for families and service promotion, and the use of new technologies. The authors call for a designated family team at each forensic unit with a lead therapist running the service and information and awareness events for staff and patients. This study belongs to a small portfolio of recently published papers that identify some interesting innovations largely concerned with PSI. In another paper, this same research team undertook a Q methodological study of both staff and relatives’ views towards family intervention, finding that both held family interventions in positive esteem. The survey by Canning et al (2009) ascertained the views of key staff on the responsiveness of different forensic services to the support and involvement of relatives. We now present specific types of service response in the relevant section below.
Service user views and involvement processes
There is limited research eliciting the views of service users on the issue of support and involvement for relatives in secure settings. The notion of ‘service user involvement’, however, can be used in practice as shorthand for ‘service user and carer involvement’ and a couple of studies of user involvement make reference to the involvement of carers in secure settings. A review across England undertaken by The National Survivor User Network (NSUN) and WISH (Voice for Women’s Mental Health, previously Women in Secure Hospitals) (2011) identified some examples of carer involvement and also the potential for more. For example, in one unit there would be regular open days for carers were they would be able to question staff and see activities. Carers might also be recipients of minutes from patient councils, and future plans in another unit included provision for regular carers meetings. Similarly, an evaluation of service user involvement (McKeown et al, 2012) across secure care in the Yorkshire and Humber region focused on service user and staff alliances, but also elicited ideas for future work. In this study, service users were engaged in workshop exercises to translate the research findings into future strategic action plans. A priority for these actively engaged service users was better support for carers/relatives and a recommendation for getting them involved in extant strategic involvement processes which to date had been restricted to service user involvement, effectively excluding the voice of carers (McKeown et al, 2012).
Types of support and services for carers in forensic settings
The key paper by Canning et al (2009) found that although a focus on carers has increased in general psychiatry, it has not done so to the same extent in forensic psychiatry. The services identified benefits of providing support as improving relationships and communication between staff and carers and improving patient well-being. Difficulties identified by NHS staff included lack of resources and stakeholder issues, such as carers’ previous negative experiences of services having an adverse impact on future engagement. This paper recommends minimum standards for supporting relatives to include:
- Comprehensive information pack for all carers
- Regular carer events
- Ideally, a regular support group
- A small group of staff to collaborate on carer support, driving the agenda forward and becoming a point of contact for new carers
An earlier survey by Geelan and Nickford (1999) remarked upon the relative lack of systematic family therapy available across English and Welsh medium secure units, with wholesale lack of staff training identified as a key limiting factor. What work was undertaken with families was poorly focused and targeted, with insufficient attention paid to desired outcomes.
The most recently published survey of this kind makes some telling criticisms of medium and low secure services in England and Wales (Cormac et al, 2010). This postal survey inquired into facilities for relatives and found that many forensic services were not meeting legal obligations for carer’s assessments and services addressing relatives’ needs were of variable quality. The authors urge that services are improved to meet standards for involving relatives and comply fully with legislation. 63% of services claimed to operate a support service for relatives, but of those that did not, 60% had no plans to develop one. Only three units out of 68 responding to this survey employed carers support workers. Only half replied that they were aware of appropriate local accommodation for visiting relatives, with only three units providing their own accommodation. Only 28% offered a carers support group with slightly fewer units offering family therapy. Just over half of the units informed relatives of their right to a carer’s assessment on discharge. The picture for ethnic minority carers was particularly bleak. While services had relatively large proportions of BME patients, 82% of the units offered no special facilities for their carers.
Carers support groups
Support groups are one of the simplest ways in which relatives can have their needs met, yet they are not at all routinely available (Cormac et al, 2010). One of the earliest papers in the field is an evaluation by McCann (1993) of a carers support group in Ashworth high secure hospital originating in 1990. This was designed in such a way to promote autonomous self-organisation by the relatives themselves following an earlier period of staff facilitation. The timing of the group was organised around visiting arrangements, so as not to inconvenience relatives having to travel long distances. Reported benefits included: being better informed, feeling less isolated, appreciating a notion of shared experience with other relatives and improving the interface with staff and care teams, especially in terms of the quality of relationships. Some relatives felt that the patients they visited also benefited from the existence of the relatives support group; for instance, in the mediation of problems and complaints and increasing levels of influence on the part of the relative in care team decisions and patient welfare.
Previous surveys (Canning et al, 2009; Cormac et al, 2010) note the patchy availability of support groups in forensic settings and recommend that these circumstances are improved. In the course of a literature review focused on service users in forensic settings who have a dual diagnosis of illicit substance use, Richards and colleagues (2009) highlight the NICE recommendations that relatives should receive information about support groups. This is also one of the principles of more general carers’ charters (see Carers’ Advisory Group: the London Mental Health Carers’ Charter, 2002).
Carer support workers
Small numbers of secure units are reported to have employed dedicated carer support workers (CSW) (Cormac et al, 2010). In a published conference abstract, MacInnes and Bressington (2011) describe the intention and methods for evaluating such a service being developed across the forensic units belonging to two NHS Trusts. The service itself aims to provide practical support and basic counselling interventions to carers with the CSWs trained and inducted into the role and also involved in developing bespoke information and publicity materials. The evaluation methods include interviews with carers and analysis of amount of contact and types of support provided. The findings have yet to be published but the authors anticipate that the service should begin to meet the demands of carers for better information and support and possibly remedy previous dissatisfaction in this regard.
The first Ashworth Public Inquiry led by Louis Blom-Cooper (1992: 233) made particular criticisms and recommendations regarding unmet needs for relatives:
…regrettably, the regime at Ashworth… seems to have been designed to deter rather than encourage relatives to participate in their relatives’ care.
The programme of psychosocial work commenced around this time led by Ged McCann and colleagues was boosted by the publication of the Inquiry report in 1992 and was instrumental in establishing a Visitors Centre, which was a newly built facility that included bespoke meeting space for off-ward visits and bookable en-suite accommodation for relatives having to travel long distances. A manager and team of staff were appointed to better service the needs of visitors and relatives. Unfortunately the later Public Inquiry into security failings, the Fallon (1999) Inquiry, was influential in the closure of the Visitors Centre after a small number of visitors to wards were implicated in serious security breaches, including one startling child-protection issue. Arguably, this small piece of history shows how strategic thinking concerning relatives has been lacking, especially in terms of applying blanket policy prescriptions without attention to specific needs, either for relatives or regarding security arrangements (McKeown, 2007).
A number of services have attempted to improve visiting arrangements, including the provision of more comfortable rooms and toys for children (see Cormac et al, 2010). Canning et al (2009) found that some units provided free telephone calls for service users to keep in touch with family or assistance for carers claiming money to defray the costs of travelling. Dimond and Chiweda (2011) describe a welcome meeting arranged soon after a person is admitted to their unit as a feature of a systematic approach to improving the therapeutic environment. Though not primarily about meeting carers’ needs, relatives are invited, and positive relationships between carers, patients and care staff are valued.
Children of forensic patients
Only one paper was found with a focus on service users’ relationships with their children following admission to forensic services. This paper by Chao and Kuti (2009) confirms the anecdotal sense that many patients have lost contact with their children. In a survey of two medium secure units in London, 69 had children but only 25 remained in contact. The authors conclude that the children of forensic patients should be seen as a neglected group because there are only limited attempts to offer them support. Forensic services should judiciously assist in maintaining contact or re-initiating contact.
Information for carers
Receiving good quality, relevant information about a range of issues is highly valued by carers in a mental health context generally. This goes beyond simply offering information, but carers also value receiving good quality information about aspects of care provision and information aimed at improving understanding of mental health. For some time, UK mental health policy has recognised this and recognised the need for two forms of information for carers:
- Specific information about the person they care for and their progress – illness, medication, side effects
- General information on a wider range of issues – research into effectiveness of treatments, legislation, MHA, local services, benefits, professionals and their roles
Within secure services, further information is required that is specific to the secure setting and the operating policies of specific units (including issues concerning interface with the criminal justice system) and practical issues such as visiting arrangements and local transport and amenities (Cormac et al, 2010; MacInnes et al, 2013). Similarly, carers in the forensic context will have information needs relating to how best to care for a family member who may have imposed significant burdens on their relationship, linked to their offence and/or violent behaviour (McInnes and Watson, 2002). MacInnes et al (2013) in a survey of two London medium secure units found that carers’ satisfaction with services pivoted on the quality of information provided, and that novel ways of exchanging information ought to be considered. Going back to possibly the start of any published interest in working with families in secure settings, Cordess (1992) identified prime aims as imparting information to carers and obtaining information from them.
Many units produce information leaflets or packs for carers, and some offer newsletters or internet-based information; written information can be posted directly to relatives, strategically placed where carers might find it, or supplied in the context of other communication with staff (Canning et al, 2009). From a policy perspective, it is desirable that service users and carers have a role in the production of such information (Kelly et al, 2010; NHS Education for Scotland, 2013). Uptake of written information by carers is high, and this is often provided as part of the admission process (Canning et al, 2009). Culturally-specific information for families of ethnic minority service users is less often available (Canning et al, 2009).
Published literature describing or evaluating information provision for carers in secure settings is thin (MacInnes et al, 2013). However, the provision of information addressing carers’ needs and negotiating access to personal information regarding the care of their relative is an implicit part of many of the initiatives described elsewhere in this review, especially psychosocial and psycho-educational approaches to support and involvement, which are difficult to disentangle in the literature (Scottish Intercollegiate Guidelines Network, 2013). For example, the early study at Ashworth (McCann et al, 1996; McCann and Clancy, 1996) involved both the production and dissemination of information for carers relevant to the high secure setting and a mixture of discussion of information, psycho-educational and support group work which was found to be beneficial for the carers. Staff suggest that barriers to the uptake of psychosocial family intervention in secure settings could be addressed by the production and dissemination of information leaflets promoting the service (Absalom-Hornby et al, 2011b).
A survey of support provided to carers in secure units found that some units referred people to voluntary sector sources of information, such as Rethink or Mind (Canning et al, 2009). The NSUN/WISH (2011) recommendation that all forensic units identify a person responsible for service user involvement could equally be extended to carer involvement.
Psycho-education approaches involve engaging service users and/or carers in learning about mental health and services so as to better realise benefits from care provision and promote mutual self-help or support-seeking (Mannion et al, 1994; Pekkala and Merinder, 2002). Such initiatives can be enacted in group or one-one formats. Typically, these efforts have been associated with the PSI approach, and the majority of studies are within mainstream, community mental health services. These have focused upon people diagnosed with psychosis and/or their carers, and the content has emphasised understandings of illness and medication, though there has also been interest in self-coping, mutual support, and various psychological understandings and interventions. A smaller number of studies have evaluated psycho-education in forensic settings, with service users alone (Aho-Mustonen et al, 2008; 2009; Vallentine et al, 2010; Walker et al, 2012; 2013) or carers alone (McCann et al, 1996). Klimitz (2006) has suggested that it is optimal to deliver psycho-education with carers and service users together, but Vallentine and colleagues (2010) point out that this is not always possible in forensic settings, especially if the index offence has been committed within the family.
Educative approaches range from simple didacticism to experiential and action methods of learning, including peer-peer learning (Perlick et al, 2011). There is a general literature on psycho-education that takes a fairly positive view of its impact, and stresses the value of enhancing carers’ knowledge so as to better enable them to resist stigma and support individual patients, and that this may help with relapse prevention (see Budd and Hughes, 1997; Sibitz et al, 2007). However, the value of psycho-education on its own to prevent relapse is limited unless also accompanied with more structured and systematic support for families, such as family therapy (Fadden, 1998; Tarrier et al, 1998).
The most commonly undertaken family work reported in Geelan and Nickford’s (1999) survey of forensic units was psycho-education. In an early Australian paper, a psycho education programme was implemented in community settings where families were caring for individuals with forensic histories (James, 1996). In this initiative, the psycho-education component was combined with emotional and practical support and was aimed at reducing anxiety levels, and preventing relapse or re-offending.
A significant amount of the available literature concerning carers and secure settings has focused upon the promotion and evaluation of initiatives informed by psychosocial understandings of mental disorder, specifically psychosis. Fundamentally, this conceives of psychotic experiences as negatively influenced by stress, treating the psychosocial stress in close personal relationships as crucially influential, and working systematically with people in the patient’s social network to better understand these links and communicate and relate to each other in less stressful ways. Some have argued that better information sharing between services and carers is the active ingredient of such approaches (Slade et al, 2007). Psycho-educational interventions and the provision of information for carers are often incorporated into broadly conceived psychosocial interventions, typically as a precursor to a more structured process of family support, or possibly as stand-alone initiatives.
Various research studies in general community settings demonstrated the value of this approach, resulting in significantly reduced relapse rates and reduced stress and burden for relatives (Pharoah et al, 2010). From the 1980s onwards, gathering pace in the 1990s with the establishment of training programmes such as the Thorn Initiative, this thinking led to a call for wholesale adoption of so-called psychosocial interventions (PSI) into services. The cornerstone would be systematic family support or family therapy, but also included were a range of individual therapies such as Cognitive Behavioural Therapy (CBT). Arguably, the rhetoric around PSI and the increased numbers of staff trained to deliver these interventions has not been matched in uptake into services, forensic or otherwise. That said, since the 1990s there have been various attempts to adopt and adapt PSI approaches, largely developed for general community settings, into forensic practice, and this was the focus of the 1999 survey by Geelan and Nickford.
The work of McCann et al at Ashworth involved the earliest programmatic undertaking to implement PSI in the high secure environment (McKeown and McCann, 1995; McCann and McKeown, 1995; McCann et al, 1996; McCann and Clancy, 1996; McKeown and McCann, 1999; McCann and McKeown, 2000) which ultimately was limited in success due to organisational impediments to systematic uptake (McKeown, 2007).
One of the interesting features of secure settings, or indeed other inpatient mental health environments, is that patient contact time with carers is limited, but contact with staff is potentially maximised. Despite carers possibly having less contact time with their family member, the psychosocial stresses involved can be substantial, making the case for concerted efforts to provide psychosocial support. For example, face-to-face visiting times can become emotionally loaded, with each person not always knowing what to say for the best, or perhaps avoiding the things they would most wish to talk about, such as the circumstances of the offence, or issues of current well-being, for fear of provoking a negative reaction or causing upset (McKeown and McCann, 1995; McCann et al, 1996). Staff could take fairly simple measures to support relatives/visitors to cope with these stresses and improve the experience of visiting. The PSI ethos is not only about support for carers; it can include the involvement of carers in the care of their family member who is detained, for example, with regard to better planning for holistic care and recovery informed by the experiences of someone who knows the person well, hence improving assessment and engagement.
A number of sources have taken forward the idea of PSI within forensic settings and how these might underpin service developments; these include at different levels of security and with different client groups such as forensic learning difficulties, psychiatric intensive care units (PICU or IPCU in Scotland) and forensic liaison, dual-diagnosis services, forensic child and adolescent mental health services (CAMHS), and community forensic services (Savage and McKeown, 1997; MacInnes, 2000; Baker et al, 2002; Walker, 2004; Isherwood et al, 2004; Gleeson et al, 2006; Lawless, 2008; Peddie, 2009; Atchinson et al, 2009; Richards et al, 2009; Absalom-Hornby et al, 2010). Walker (2004) described the adoption of PSI practices into the State Hospital at Carstairs.
Most recently, Absalom-Hornby and colleagues at Manchester University published an interesting cluster of papers reporting their research into PSI in secure settings. This has involved the innovation of using web cameras to conduct family therapy remotely for families who cannot visit frequently because of distance (Absalom et al, 2010; Absalom-Hornby et al, 2011a; Absalom-Hornby et al, 2011b; Absalom-Hornby et al, 2012). The use of digital technology to facilitate family support was found to be successful, was not off-putting for families and indeed was appreciated, positively impacting on social, emotional and practical outcomes for the families concerned (Absalom-Hornby et al, 2012). These authors surveyed 11 wards in secure units in the North West of England across all levels of security. They found that only 18% offered any form of family intervention, despite 72% of patients having high levels of contact with their carers (Absalom-Hornby et al, 2010). This confirmed the findings of an earlier audit as to whether any forensic service was meeting NICE guidelines for the care of individuals diagnosed with schizophrenia. In this study none of the 30 patients were offered family intervention and only half reported having received relevant information about their diagnosis or treatment; in short, the unit failed to meet any of the NICE standards (Gough et al, 2007).
Forensic community services are surprisingly under-represented in the literature regarding carers. An Australian paper by Gleeson et al (2006) makes recommendations supported by a literature review for what they refer to as preventive forensic PSI within mainstream adult community mental health services to better meet the needs of patients with a history of offending. McKeown (2001) presents a single case study focused on the community support of a family along with their relative recently discharged from a low secure unit to live at home with his mother. The care team provided family PSI to good effect, with a significant positive impact on well-being, illicit drug consumption and associated criminality and reduced levels of stress in relationships at home.
Case management and risk assessment
It is generally accepted in the professional rhetoric of policy and mainstream services that the involvement of carers can make a positive contribution to case management and the operation of holistic models of care (Hervey and Ramsay, 2004; Wallcraft et al, 2011). Policy urges more involvement of carers in the care of forensic patients (NIMHE, 2004). Some authors have made the case for a more systematic approach to involving carers in the risk management approaches salient to forensic services, such that services should view carers as a resource in this regard (McCann and McKeown, 2002; Nordstrom et al, 2009). In any event, in general community settings carers report a number of informal ways in which they attend to risk in the care of family members, though they speak of this in a different language from professionals (Ryan, 2002). Kennedy (2002) proposes a system for stratifying risk across the different levels of secure care which takes account of the degree of supportive family involvement as a positive factor in risk management.
In the Irish context, Gill et al (2010) propose adoption of an Integrated Care Pathway approach to re-engineer services from a traditional focus on security towards a more recovery-oriented system, opening up the possibilities for enhanced service user and carer involvement. This would involve a number of implications for practice including: provision of a framework whereby patients and carers are enabled to identify and understand risks and needs, improving partnerships with carers and patients in consideration of the foundations for recovery. Similarly, Kelly et al (2002), writing in the Australian context, propose a model of community forensic care that positions carers as key partners in drawing up risk management plans and actioning them. The general requirement to undertake a carer’s assessment and for carers to be involved in discharge planning could be neatly tied into such ideas around collaboration, partnership and risk management (see Simons et al, 2002; Rapaport et al, 2006).
 A carer has a right to ask their local authority to carry out an assessment of his or her needs. The local authority has a duty to carry out the assessment within 14 days of the request. If it does not it must let the carer know within this time whether they or the Health Board will carry out an assessment. If the local authority decides not to carry out an assessment they must give their reasons for this (Scottish Executive, 2006).