Services for the relatively small number of people with intellectual disabilities who are at risk of criminal offending have been much neglected in the past. Professor Glynis Murphy from the Tizard Centre (University of Kent, UK) reviews the reasons for this and identifies the type of information which is needed if quality services are to be developed for this group.
Professor Murphy notes that when ‘mental handicap’ hospitals existed, it was not unusual to find that there were some relatively able people there who had been incarcerated originally for minor misdemeanours (such as taking a bottle of milk from a doorstep). These people then often languished in hospital for no clear reason and received little or no treatment. With the advent of community care, many such people were often the first to be resettled out of institutions; however, if they re-offended, services were often at a loss how to provide suitable health and social care for them.
In terms of health care, people with intellectual disabilities at risk of offending were often rejected by mainstream mental health services as being too difficult to treat and by disability services as being too able and sometimes too dangerous to live in staffed group homes. The consequence was that service providers grew to dread this particular group, as they frequently felt driven to provide expensive placements, with no clear idea of how to make progress in services. Furthermore, attempts to provide services for this group are often complicated by a perception that there is a conflict between service users’ rights and public safety. This apparent conflict can arise from the irrational nature of human estimates of risk and the, at times, near-hysterical media coverage given to unusual violent attacks on members of the public by people with mental health problems. Research has shown that people discharged from mental health services are no more likely to be violent than others living in the same area.
Findings show that 5% to 9% of people interviewed as suspects by the police have an intellectual disability, yet little is known about the effectiveness of different types of interventions and rehabilitative service models. Information is needed on the validity of risk assessments, levels of security which people really require, the effectiveness of cognitive-behavioural treatments and psychotropic medication, specialist staff training required, and the degree of interagency and professional coordination which is needed if quality services are to be developed.
Policy and trends
Glynis Markham, Deputy Director of the High Security Psychiatric Services Commissioning Team in the UK, reviews the policy framework and current trends in the provision of forensic mental health services. The policy framework in Britain is influenced by political, social, humanitarian and economic factors, and in particular by the WHO document Mental Health Care Law: Ten basic principles (1996). This document advocates that mental health care services should ensure the promotion of mental health and prevention of mental disorders within the least restrictive environment, the availability of review procedures and the rights of service users to be assisted in the exercise of self-determination.
In translating policy into action several issues must be addressed. Services need to become patient-focused and be sensitive to individual needs. Viewing forensic patients as a homogeneous subgroup of general psychiatry or intellectual disability services in need of custody and care is no longer appropriate.
In the future it is hoped that specialist treatment and care services will exist for different groups (e.g. sex offenders, substance abusers, self-harm groups) which cater for individuals requiring all levels of security. Mental health, intellectual disability and social services and the criminal justice system will share expertise and work together in areas such as case management and assessing risks to public safety. Rehabilitative programmes will focus on offenders taking responsibility for their actions and developing self-help skills. Health care professionals will need to develop clinical leadership that can embrace and manage change and service developments. They must also acquire the leadership skills necessary to sustain and retain skilled workers in challenging roles.
These new models of service delivery will need to be researched and evaluated carefully to ensure that they are effective. Strategies for workforce planning, education and training of staff will need to be developed, and the financial implications of these new services considered.