What are forensic mental health services and forensic carers?
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 (Scotland’s Forensic Network).
Forensic carers then are people of any age who provide unpaid support for a relative or friend who is using forensic mental health services, including people in low, medium and high secure hospitals like the State Hospital, as well as in community settings such as day hospitals and Community Mental Health Teams.
Support in Mind Scotland (SiMS) and the Forensic Network asked a research team led by the University of Central Lancashire to review support for forensic carers in Scotland.
They wanted to know:
- what support is provided by forensic mental health services for carers
- what support do carers find helpful
- is there a gap between what staff think is available and what carers receive in practice
- what works well and what prevents carers from accessing support.
What we did
We used a number of ways to build up a picture of how forensic carers get support, including:
- Looking at books and papers that have been written about support for carers and what is found most helpful.
- Sending a questionnaire to forensic mental health services to ask about what they do – 79% of services responded.
- Sending a questionnaire to forensic carers to ask about their experiences – 66 forensic carers from across Scotland responded.
- Interviewing 19 forensic carers across Scotland.
- Forensic carers often prefer to use other words than carer to describe their role, including ‘visitor’ or ‘supporter’ or ‘mum’, ‘brother’ or ‘friend’.
- Some people who were carers, and some staff in forensic mental health services, thought that they couldn’t be a carer if the person they support was in hospital.
- Many carers had experienced periods of time when the person they support hadn’t wanted them involved. This didn’t stop carers from worrying and caring about their relative.
- Forensic carers provided emotional and practical support, as well as visits. They also looked to the future when they may need to provide more support after the person was discharged from hospital.
- The caring role could be stressful and affect carers’ physical and mental health, as well as impacting on other aspects of their life, including losing friends through the stigma of being a forensic carer.
- Services estimated that under half of forensic carers used the support they provided, highlighting the main reasons as being carers’ choice, stigma, and travelling long distances to visit.
- Carers commented on improvements in forensic mental health services in recent years. However they still felt there was some way to go before the individual needs of their relative, or their own needs as carers, were met.
- We heard many examples of good practice including information leaflets about forensic services, carer support workers, carer support groups and behavioural family therapy.
- Carer support varies a lot across Scotland as a whole, and sometimes within the same service. This can make it difficult for carers to know what is available, especially when the person they support moves from one service to another.
- Carer support groups were an important form of support for many, although it was difficult for them to attend groups run by specialist services when these were at a distance.
- Many carers reported not being listened to when they raised concerns about their relative’s deteriorating mental health before admission to forensic mental health services.
- Staff said carers choose not to be involved, but carers described it being difficult to get information, or they didn’t always feel included by services as much as they wanted.
- Carers genuinely appreciated those members of staff who took the time to communicate actively and involve them in the person’s care plan.
The growing emphasis in health and social care policy on the importance of supporting and involving carers needs to become widespread practice. The benefits of such an approach suggest this is achievable without compromising confidentiality or risk management. We concluded that in order to improve support to carers, services need to implement the general recommendations from the Triangle of Care policy document:
- Carers, and the essential role they play, should be identified at first contact or as soon as possible thereafter.
- Staff should be ‘carer aware’ and trained in carer engagement strategies.
- Policy and practice protocols regarding confidentiality and sharing information are required.
- A defined post(s) responsible for carers should be in place.
- Carers should be introduced to the service by staff and provided with information across the care pathway.
- A range of carer support services should be available.
To meet the specialist needs of forensic carers in Scotland, we also recommended that:
- Existing good practice, where forensic mental health services are working together with carers, should be shared more widely.
- There should be named staff as a point of contact for new carers and also to take a lead on the carers’ agenda within each service.
- Services should provide an information pack for carers, which should be in a range of formats and languages.
- Services should give extra information, advice and support to carers when the person they support moves to a different service.
- Carers should have access to advocacy.
- Services need to work with forensic carers to challenge the stigma of being a forensic carer.
- Forensic carers should be involved in support planning and reviews.
- Forensic mental health services should hold regular events for carers including open days on secure units.
- All forensic mental health services should support a regular carer support group run by the unit, the voluntary sector or carers themselves, and learn from existing successful groups.
What happens next?
Support in Mind Scotland (SIMS) and the Forensic Network will work with carers and staff in the services to produce guidelines for good practice and a way of helping staff measure their effectiveness in involving carers more in the care and treatment of their relatives. The report will also be used to carry out further consultation and discussion amongst carers so that we ensure that carers themselves know about and can refer to the findings.
The research team are grateful to everyone who helped us, including the Working Group and staff in forensic mental health services throughout Scotland. We are particularly grateful to the relatives and families who shared their experiences of carer support with us, with the aim of improving support for all forensic carers in Scotland. We hope this report makes a difference.