Mentally ill offenders: Our fear of introducing them back into society
Forensic nursing is one of the most demanding and misunderstood areas of care in the NHS. Nursing manager Theo Bello gives an inside view about the challenge of working with mentally ill offenders and public fear about their release back into society.
Mental health is one of the least popular areas of nursing and you can go one better – by specialising in forensic nursing which looks after offenders whose mental illness precludes them from prison.
At present, there are about 4,000 patients being treated in secure units around the UK for a variety of conditions. Typical crimes include murder, rape and sexual offences influenced by accompanying mental illnesses including bi-polar, schizophrenia and personality disorders.
Everyone coming into a secure unit is assessed before admission and we get our fair share of fakers who pretend to be ill thinking life in a forensic unit is preferable to prison. However, it’s difficult to fake mental illness for any length of time and it is often people’s rationality that trips them. People with full-blown psychosis are genuinely distressed and that can be someone who is climbing the walls or standing stock-still for hours at a time.
I can’t pretend nursing started as a personal choice for a vocation, but it has certainly become one in the 15 years since my initial career in civil engineering hit the rocks after my overseas qualifications weren’t recognised in the UK.
I remember asking a careers advisor at the time what was the most cast-iron job in terms of employment and demand, and he said people were always going to get sick so why not try the NHS?
Nursing can be a tough profession, but also a very rewarding one and you learn a lot about yourself in the process – especially in an environment like forensic services. People do however carry a lot of preconceptions about working on secure wards. I know I did before I joined the service, with the usual concerns about the threat of physical violence and wondering if I could work with people who’d committed some disturbing crimes.
I remember one patient who had murdered his girlfriend’s child while she went out to get a pint of milk. He calmly sat down after leaving the body in the kitchen, lit a cigarette and waited for her to come back as if nothing had happened. This really shook me up because I had a child of same age at the time and I just kept re-running it through my mind. I was looking at this patient’s actions with my own moral compass and values which is pointless when someone has a serious mental illness.
People do the most shocking and bizarre things but at some level it makes perfect sense to them even if it leaves the rest of us shaking our heads in disbelief.
Our job is to find out why patients behave the way they do, what triggers their behaviour and if their condition can be effectively treated.
I’d say good communication skills, empathy, maturity and respect are key skills in being a good mental health nurse, along with a commitment to build a strong therapeutic relationship with patients and colleagues.
A lot of incidents involving confrontation are down to a perceived lack of respect that staff shows patients. It’s something we work hard to bridge because so much rests on it. Just a fraction of a correction in that social interaction makes a huge difference and everyone gets what they want.
One of the biggest conflicts of interest I have is restraining a patient from hurting themselves or others. I personally struggle with the fact that I am here to build relationships with patients and help treat and support them yet may also be called upon to restrain them if they become violent.
At present, we’re at something of a watershed in forensic services because we need more effective mechanisms for getting patients back into the community which is free from political interference.
There is huge public fear around mental health and that irrationality goes through the roof when a murderer is mentally ill.
The circumstances are tragic but no-one can provide a cast iron guarantee that any offender won’t commit another crime on release and that fear is multiplied when it involves mental illness.
Politics, sensationalist media coverage and widespread public prejudice about mental illness are a potent cocktail that keeps us in stalemate because it’s the safest position to occupy. Ideally, all mental health services will maintain a safe and effective process of treatment and rehabilitation through the stratification of patients according to the risks they present.
I believe specialised community housing, a close-knit support group of mental health workers and close monitoring would all make a move into the community more effective in the long-term.
Re-offending rates are low compared to those leaving the prison system and the chance of an individual being murdered by someone with a psychosis is about one in ten million – the same as being struck by lightening.
A revised approach has to be found and it’s a case of who is going to be brave enough to seek a new way forward free from the blame game when a serious incident does take place.
Theo Bello is a nursing manager with Barnet, Enfield and Haringey Mental Health NHS Trust and oversees the management of several low and medium secure units at Chase Farm Hospital in north London.Tagged in: forensic nursing, healthcare, mental health, nhs
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