Social inclusion for all? meeting the needs of low secure service users

Standard one of the national service framework for mental health (DH, 1999) requires health and social services to promote social inclusion for all. Users of secure services are, arguably, the most excluded of all those in the care of mental health services and thus the most in need of active social inclusion. Yet they are the least able to participate in the community-based programmes that would help them re-engage with ordinary living following discharge. In this article Rachel Wakefield and colleagues describe the obstacles they had to overcome to introduce a socially inclusive resettlement programme for service users in the low secure unit where they work.

Forensic services are specialist services that sit within adult mental health services. Users of forensic services are individuals that have come into or are likely to come into contact with the criminal justice system as a result of their risky behaviour. Services are provided in the community or, if an individual is seen to present increased risk, in low, medium or high secure establishments. All inpatient forensic service users are detained under the Mental Health Act.

We work in a low secure forensic unit run by Lincolnshire Partnership NHS Trust. The definition of a low secure unit is one that 'delivers intensive, comprehensive, multidisciplinary treatment and care by qualified staff for patients who demonstrate disturbed behaviour in the context of a serious mental disorder and who require the provision of security' (DH, 2002). Such units aim to 'provide a homely secure environment, which has occupational and recreational opportunities and links with community facilities' (DH, 2002). Service users present with severe and enduring mental illness or, less commonly, personality disorder. Individuals may be accessing secure services for the first time, or they may be 'stepping down' from conditions of higher security.

The risk of social exclusion

It is clear to us that forensic service users are at greater risk of social exclusion than those using general mental health services, for a range of complex but related reasons.

Erosion of living skills

Central to a person's ability to live a full and meaningful independent life is their ability to care for themselves, which includes accessing a range of community and social experiences. However, many forensic service users may find their living skills are eroded, not just by the severity of their symptoms, but because of long-term hospitalisation typically associated with this client group. The recommended length of stay in a low secure unit is two years (DH, 2002) relatively brief - but low secure service users may have previously spent many years in conditions of higher security. Hence the loss of their skills and confidence may have started long before they are even admitted to conditions of low security. Clinical staff - occupational therapists in particular - can offer opportunities to practise and maintain skills, but opportunities may not be frequent enough.

Risk management

Risk assessment and management will also affect such opportunities. Service users are risk assessed for their suitability for all activities, and community activities may be affected by restrictions imposed by the Home Office. For example, some service users may be required to have a staff escort or may have restrictions placed on the time of day and locations they can visit. It may be that activities have to be adapted to enable the service user to participate in them.

One such example would be accessing normal community resources such as the local library. The process may typically involve a formal request to the Home Office for consent to access the community, further risk assessment and agreement by the multidisciplinary team, arrangement of staff escorts, booking of hospital transport and the completion of 'leave forms' detailing time out, time due back and even the clothes to be worn by the service user.

While risk management must take priority, this process will inevitably be a less normalising experience than it would be otherwise, and the resources required may limit the frequency of such community activities. Yet without regular access to the community, how can forensic service users feel confident, competent or included within their community? It seems probable that the longer they are isolated from their community, the more isolated and excluded they will feel.

Ultimately, a service user's ability to care for him or herself will affect both the nature and the quality of their future placement and the length of time it will take to reintegrate them successfully back into the community. Hence, it would seem more ethical and a more efficient use of resources to try to prevent the erosion of confidence, skills and feelings of social exclusion in the first place, as exemplified by the aims of the Social Exclusion Unit report (2004).

Offending behaviour

We know that mental health service users are one of the most stigmatised and discriminated against groups in society (Social Exclusion Unit, 2004). Although not specifically referred to in the Social Exclusion Unit report, it would seem likely that forensic service users are at much greater risk of experiencing stigma and discrimination. This will affect their ability to participate in and enjoy a full range of social and community experiences. Not only do many have offending histories, but the nature of their offending - which could be violent and/or sexual - may be such that they are perceived by the public as at best deviant or, at worst, monsters.

Many also face additional barriers to their social inclusion. For example, a review of recent studies suggests that a significant percentage of forensic service users have substance misuse problems (Whyte & Harrison, 2004), and the Social Exclusion Unit report highlights such complex needs as a particular barrier to inclusion.

Our approach

At the unit, we felt that our service users were at increased risk from social exclusion because of the issues outlined above. Over the last three years an occupational therapist has worked with colleagues in nursing and psychology to develop a resettlement group programme that tries to promote social inclusion through both the aims of the group and the group processes themselves.

While the group is still evolving, we felt that it might be useful for others to hear about the challenges we faced and our successes in applying socially inclusive principles to a group that is too often marginalised from society. We are aware that many colleagues in forensic services are passionate about and actively trying to promote the social inclusion of their service users. However, this does not yet seem to be reflected in the current literature.

Aims of the group

The most recent group (2004-2005) comprised eight service users who were self-referred and had been identified by the multidisciplinary team as suitable for a move to less secure conditions. The key aims of the group were:

* to provide information, discussion, support and practical opportunities to develop living skills in preparation for a move to a community based setting

* to promote confidence and skills in accessing and participating in a wider range of social and community experiences, including education, employment and leisure

* to promote the social inclusion of low secure forensic service users through the group process itself.

Planning the programme

Group members were asked to complete a specially designed questionnaire that asked them to indicate topics they would like to see covered in the group by rating topics as either very useful, useful or unhelpful. The topic areas offered were influenced by the SNQK questionnaire (Davis et al, 2002), and included topics such as employment, social confidence, benefits and bills, resources, stigma and discrimination, and support for mental health service users.

The facilitators then analysed the responses in order to identify the most popular topics. A group planning meeting was then arranged at which the most popular topics identified through the questionnaire were presented to the group. Group members were then asked to identify information or questions about these topics that they would like explored further (see table 1, which uses 'Employment' as an example).

Following the group planning meeting, the facilitators devised a 12-week programme that covered the areas requested (see table 2). It was envisaged that each session would consist of information giving, role plays, sharing experiences and anxieties, visiting speakers or community visits, practical tasks and group problem solving.

The group

Our group facilitators have used Dodd and Loeb's (1998) principles of social inclusion. These principles include:

* shared decision making. An adult learning environment was encouraged through group decision-making. Members were asked to choose the group name, course content, session duration and break times

* addressing underlying feelings of powerlessness. Traditionally within the medical model, the patient is a passive recipient of care. Involving group members in the planning and delivery of the course represented a move toward increased empowerment. Validation of group members' experience and expression of opinions was encouraged through discussion and disclosure

* developing life skills. All the courses offered aimed to promote inclusion by developing life skills to enhance independent living. These included, for example, problem solving, building supportive relationships, work skills, study skills, coping with stigma/discrimination, identifying leisure interests, improving social confidence, knowing your rights, and money management

* facilitating participation. Where possible, members were given the opportunity to participate in practical sessions in the community. For example, on one occasion members were asked to agree, plan and participate in a community leisure activity, while keeping to a budget. Again, it was felt that, wherever possible, sessions should encourage confidence and skills in using mainstream community resources

* building supporting networks. Where feasible, outside speakers were invited to attend the group. We had a visit from a local employment project, and members clearly found this extremely useful. It was hoped that this would give members the confidence and resources to use this service following their discharge. It was also an opportunity to build bridges between the forensic service and the wider community.

* promoting access to information. Many forensic service users do not have internet access. We believe that this contributes to their social exclusion. Hence supervised internet access was provided in order to promote an activity that most of us take for granted.

Obstacles

A major obstacle to socially inclusive practice in low secure services is organisational culture. In the traditional medical model, staff are seen as experts on the patient's condition. While we are fortunate to work in an environment where the staff team are actively trying to promote service user involvement, other clinicians may not yet be in the same position.

Another problem is having to work with limited resources. Working in a socially inclusive way within forensic services is labour intensive and time consuming, all of which cost money.

The process itself raises difficulties. Encouraging service users to be involved in the planning and delivery of the programme means that every programme will be different, as it will reflect the needs of its current membership. This requires facilitators to be constantly providing new material, which is very time consuming. Furthermore, community-based sessions for forensic service users are, by their nature, time consuming. It will always be a challenge to provide community sessions within limited resources. These challenges require a service culture that is fully committed to the social inclusion of its service users.

While users of non-secure services are encouraged to be involved in decision making about their treatment, users of forensic services are likely to feel that they are obliged to attend sessions if they want to move on. It could be argued that some service users may have felt pressured to attend and participate in the group. Hawks (1992) argues that this is a feature of a controlled environment, and that it militates against empowerment of the service user.

It was always agreed that, where possible, members should be given opportunities to develop their skills within their local community. For example, individuals might be asked to locate and collect information on useful services such as the local college. However, this often proved extremely difficult. Some forensic service users require staff escort to access the community, and on occasions resources were not available for this. Earlier courses tended to be offered only to those with unescorted leave, to avoid this problem. Even if group members temporarily lost their leave, group facilitators could stand in as escorts. However, this inevitably meant that groups were small, despite consensus that the course should ideally be offered to more service users, and earlier in their admission, to try to prevent feelings of social exclusion and deterioration of skills. Consequently, there were times when the course had to be theory-based rather than practical.

Using external speakers required careful risk assessment and management. Visits had to be agreed with the ward manager, and bookings made well in advance. It was difficult to be flexible about the times of the visits, because the group was at the same time each week to fit in with the overall ward routine. Safety of service users and visitors was always paramount, and visitors had to be escorted at all times. Only visitors from known organisations were used, to avoid having to conduct criminal record bureau (CRB) checks. Again, the amount of planning involved in organising outside speakers meant that this did not happen as often as we would have liked.

There is a drive in the modern NHS to provide outcome measures for all treatment interventions in order for services to develop and thrive. Yet arguably the best feedback regarding the effectiveness of any intervention is that from the service user. We provided opportunities for verbal and written feedback after each session and at the end of the course, and we felt that feedback was generally positive and, most importantly, honest.

However, we felt we needed to ascertain if there had been any change in service users as a result of the course, and so asked participants to complete psychometric measures at the start, mid-way and at the end of the programmes. Facilitators observing the completion of the psychometric measures felt that service users found this process time consuming and meaningless. We believe that, given the choice, they would not have chosen to complete these measures.

Conclusions

The last three years have provided an invaluable opportunity to learn about the challenges of trying to promote the social inclusion of low secure service users. We believe that socially inclusive practice is the most effective way of working with these service users. It gives them opportunities to be part of their community, to develop skills that will increase their independence, and to be central to the planning and delivery of their treatment. Our experience and that of colleagues working in forensic services suggest that any intervention using a socially inclusive approach will be more effective, as service users are more likely to participate fully.

We would argue that a truly effective balance between socially inclusive principles and risk management has yet to be found. However, we believe that socially inclusive practice is the most personally fulfilling way of working. It enhances the therapeutic alliance and allows us to convey a genuine sense of optimism to our service users. We hope that one day all forensic services will be actively trying to promote the social inclusion of their service users.

References

Davis FA, Burns J, Lindley P et al (2002) Evaluation: assessing individual needs using the support needs questionnaire. In: Bates P (ed) Working for inclusion. London: Sainsbury Centre for Mental Health.

Department of Health (2002) Mental health policy implementation guide: national minimum standards for general adult services in psychiatric intensive care units (PICU) and low secure environments. London: Department of Health.

Department of Health (1999) National service framework for mental health. London: Department of Health.

Dodd C, Loeb D. Cited in: Naidoo J, Wills J (1998) Practising health promotion: dilemmas and challenges. London: Bailliere Tindall.

Hawks J (1992) Empowerment in nursing education: concept analysis and application to philosophy, learning and instruction. Journal of Advanced Nursing 17 609-618.

Social Exclusion Unit (2004) Mental health and social exclusion. London: Office of the Deputy Prime Minister.

Whyte S, Harrison C (2004) Substance misuse services in secure psychiatric units. Medicine, Science & Law 44 (1)71-74.

Rachel Wakefield, Senior occupational therapist Noel McGrath, Assistant psychologist Terence Holliday, Staff nurse, all at Lincolnshire Partnership NHS Trust

Contact: rachel.wakefield@lpt.mhs.uk; noel.mcgrath@lpt.nhs.uk; terence.holliday@lpt.nhs.uk

With thanks also to Gemma Grewer, Philip Mason and the many service users who have contributed to the development of this programme over the last three years. We would also like to thank colleagues who have supported us in writing this article.

Copyright Pavilion Publishing (Brighton) Ltd. Aug 2005
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