Ahead of our Forensic Research Nottingham 'Summer Symposium' on 14 July, Dr Danny Whiting shares his experience of providing mental healthcare in secure settings, and the unique challenges this presents.
What is forensic psychiatry?
Forensic psychiatry is a unique medical speciality with multiple facets. We work in secure hospitals, with the central remit of providing humane care to people with serious mental illness who have violently offended. We might advise the Court on the relevance of mental disorder to an offence, or whether treatment in hospital should be considered as an alternative to a prison sentence. We also work to meet the mental healthcare needs of those in prison. Operating at this juncture between the medical world and criminal justice system can be diverse and stimulating, but is not without its challenges.
We often encounter extremes. Individuals' background might reveal major trauma or disadvantage, or they may have developed a mental disorder that is profound and debilitating. It may be that a first episode of illness culminated in contact with the criminal justice system, and individuals and their families are faced with adjusting to both illness and offence. Even the most extreme illness is possible to recover from however. Many individuals gain relief from symptoms, regain function and quality of life, and over time can safely reintegrate into life in the community with different levels of support.
Treatment resistance
For some however, symptoms might prove resistant to standard treatments. This might simply be due to the nature of the illness. Or perhaps caused by the intersection of different needs and diagnoses. Treatment resistance in forensic psychiatry is a key challenge. Individuals whose symptoms do not resolve may end up spending long periods in institutional settings. We need better understanding of this phenomenon, and more treatment options.
Our other role, of providing mental healthcare to people in prison, has its own set of challenges. Here, we strive for equivalence of care. The principle that people in prison should not be disadvantaged in their access to mental health treatment by virtue of being in prison has featured in national strategic plans for many years. Achieving equivalence is not without its barriers however. Largest among them is that the prison system is not based around providing healthcare. Prisons are institutions set up to securely contain those serving a custodial sentence, and centre on this regime. Provision of healthcare has to fit around this world.
Clozapine in the prison setting
This can have significant implications for those with treatment resistant psychotic illness who reside within prison. For example, there may be practical barriers to accessing a medication – clozapine - that is used when other treatments have been ineffective. There is good evidence that clozapine can help where other medications have failed, but it has some rare but serious side effects that require close monitoring when starting treatment. These issues prove enough of a barrier in the community, with there often being a considerable delay in this treatment being first offered. Its use in prison is rare, despite the prevalence of psychotic illness in prison being around 4%. How we operate the same threshold for initiating this potentially effective medication in prison is a neglected topic.
Treatment resistant psychosis is the theme for our Forensic Research Nottingham summer symposium in July, where we will be discussing some of these needs and challenges, including how treatment might practically be approached in the prison setting.
Dr Danny Whiting is based at the Institute of Mental Health and works clinically in Nottinghamshire Healthcare NHS Foundation Trust’s prison mental health services. After completing his higher training in forensic psychiatry as an NIHR Academic Clinical Fellow he was awarded an NIHR Doctoral Research Fellowship to complete a PhD, based at the Forensic Psychiatry Research Group in Oxford. His primary research interests are in applying prediction tool approaches in psychiatric settings, as well as clinical forensic research and the epidemiology of violence in mental illness. He is co-chair of the Forensic Research Nottingham Group.