Forensic Psychology in a Regional Secure Unit

For this ‘Psychology in practice’ article, Sue Cavill visited Ged Bailes at work I the Norvic Clinic Forensic Unit in Norwich

From ‘The Psychologist,’ July 1977, ps 313-315.

Ged Bailes says, 'Cracker has a lot to answer for'. The award-winning TV serial has led to increasing numbers of students and sixth-formers asking him about becoming a forensic psychologist, with only a hazy idea of what it involves. And Fitz himself, 'could do with some supervision to help him deal with his own lifestyle'.

A visit to the Norvic Clinic Forensic Unit in Norwich, where Ged works as Consultant Forensic Clinical Psychologist shows that the work of a forensic psychologist is less about glamour and excitement and more about painstaking, day-to-day analysis, assessment and treatment.

'Our work is mainly with mentally ill and non-mentally ill offenders who have committed violent or sexual offences,' says Ged. The Clinic, a Regional Secure Unit (RSU) run by Norfolk Mental Health Care Trust, has 3 beds, plus four beds in a nearby hostel. It is usually full, with a waiting list of around 15-20 people. Ged has been at the clinic 11 years.

Complicated

The provision of care for mentally disordered offenders can seem complicated to an outsider, and only hits the headlines when something goes wrong.

There are a number of main referral sources from which mentally disordered offenders come to RSUS. Special hospitals refer patients for rehabilitation; courts refer patients for assessment under the Mental Health Act, or for treatment and rehabilitation in conditions of security. Some of these people may be under restriction orders which mean they cannot even go out into the grounds unless the Home Office gives specific permission. Prisons are the third referral point, and people may come from them to an RSU either on remand or after sentencing. They are also under various restriction orders from the Home Office.

Ged and his colleague, Forensic Clinical Psychologist Jennie Sedgwick, are part of a far larger team of professionals, including psychiatrists, nurses, social workers, adult education teachers, occupational therapists and physiotherapists. Together, they put together a care plan for each patient in the clinic.

The psychologists are usually involved from the earliest stage, helping with assessment. They then work with the team to establish treatment for the patient. The long-term aim is to bring the patient to the point where he or she can once again live in the community at no danger either to him or herself or to the public.

The Unit has three wards. They are reached through two locked doors, one of which will not open until the first is shut. Thorpe Ward is more structured than the other two, and the hope is that the patients who start their stay there will finish in the least structured and restrictive environment, gaining more and more controlled access to the outside world before they are finally ready to leave.

There are different therapeutic activities, including a library, a gym, gardening, caring for birds in an aviary, and making things in a well-equipped workshop. Here there is a dolls' house in one corner, a series of paintings in another. Tools lie around a workbench, although closely supervised by staff.

There is a 'seclusion room' within one of the wards, but this is rarely used. If a patient is in seclusion, he or she is checked every 15 minutes.

Each profession brings a different approach to the care of patients, and this can sometimes lead to lengthy discussions before final decisions are made. For example, there was once a suggestion that a particular patient who was making inappropriate comments to female staff should be given a drug which would suppress his sex drive. Ged suggested that he should be observed and assessed more, and after a period of observation it was decided that he did not in fact nee the drug.

However, Ged is keen to point out that he does agree with medication. 'You hear people say, “psychologists don' agree with medication". Well, the ones I know do.' The advantage in the psychological approach, as he sees it, is that psychologists have a unique approach to assessing problems which may mean that treatment can be modified or applied differently. 'Sometimes it can feel as if it's our job to pull everything together.'

Cognitive behavioural approach

Ged and Jennie adopt in general a cognitive behavioural approach to the assessment and treatment of patients, as they've found this seems to have the best results.

Jennie says, 'When we're treating patients it's not just a package we apply to them all. Each treatment plan should be based on an individual assessment, in order to address the specific needs of that patient. And psychology is involved in bringing unique approaches to help other staff understand what's happening.'

And they can also use their psychology on occasions to help the other staff with general issues which arise out of the work. Ged described how he had helped staff within the clinic following a patient's suicide, a particularly serious violent incident, and in connection with two cases where offences had been committed against children.

Ged and Jennie find they use psychometric tests fairly sparingly. 'There has to be a valid reason to use them, for example, if a patient's cognitive abilities have deteriorated recently.'

As well as treating the in-patients, th Norvic Clinic is involved in an active outpatients programme. Outpatient may be referred from prisons, from general psychiatric settings, or community settings, social services, probation officers, other psychologists and psychiatrists, and community psychiatric nurses. Often, these patients are people who may not have offended, but are causing concern for one reason or another, perhaps because of bizarre behaviour, threats, or persistent aggression. Sometimes the psychologists may not actually see the patient, but simply be consulted by, other professionals about aspects of a case. On occasion, a client may have problems which are not to do with offending, and then Ged will recommend that they see a general clinical psychologist.

Ged says, 'The Norvic Clinic is a base for a regional forensic psychiatric service, and is developing as a community service.'

The key concern with some of the outpatients is that they might offend. 'Nothing is worse than someone who has done nothing- wrong yet, but might. One of my most worrying outpatients was a person, outwardly very respectable, but emotionally and physically very abusive to his partner. After many sessions of treatment he just walked out, and I was worried about what he might do to her, or what she might do to him.'

Because the patient had not actually been convicted of anything, there was nothing that could be done. But where patients have offended, often very seriously, the whole issue of risk assessment is absolutely crucial. 'Risk assessment is a risky business,' says Ged, 'the reality of human behaviour is more complex and grey than black and white. You have to balance the seriousness of possible outcomes and the probabilities of their occurrence with the needs of the patient. One must never be complacent about potential risks. In all secure units people go out for weekend leaves, day visits. We also have to take serious account of any concerns raised by the Home Office, Courts and the public, but if you're trying to treat and rehabilitate patients there comes a time when the security and structure has to be reviewed, whilst carefully monitoring potential risks. We pride ourselves on being extremely careful without being unnecessarily restrictive to the patient.'

He uses the analogy of driving a car, 'There's a risk inherent in the activity, but you do all you can to reduce that and hope nothing will happen - ever.'

To place the matter in context, Ged says that during the 11 years he has been at the Norvic, very few patients have absconded, with no serious problems caused. He thinks for a while, and then remembers a patient who attempted to reoffend after he was released. But this was clearly a rarity.

In answer to the suggestion that some offenders should be locked up for life, Ged talks about those who are not mentally ill, and so are not treated in clinics, and simply serve a prison sentence: 'The majority of people who commit serious sex offences are not mentally ill, and therefore after they have served a sentence they are released. We are working within a legal system that puts constraints on things. We are balancing individual civil liberties with the protection of the public: one can see the problems and appreciate people's concerns, but we are bound by the laws of the land. We can't section someone under the Mental Health Act if they are not mentally ill, even though they might be doing bizarre things.'

Coping

Inevitably Ged and Jennie do work with people who have committed horrific crimes. So how do they cope? Both psychologists have supervision so that they can discuss any difficult elements of their work with another professional. They are also members of the Forensic Clinical Psychologists Group. This is a national network of clinical psychologists who work in RSUs and community forensic clinical settings. They meet twice a year to share information and discuss work-related issues.

Jennie says that she becomes absorbed in the cases and issues the patients raise. Ged says, 'I find it fascinating - I suppose you could say I get paid for being nosy!' They both enjoy the challenge of using a range of skills, and dealing with different organisations. 'You feel the work is like a puzzle. You don't become immune to what people have done, but you can become inoculated,' says Ged.

The unique element of their approach as psychologists is that, drawing on past psychological research, they have a model of 'normal' human behaviour, which they can consider when approaching abnormal behaviour. 'The work is about putting one person's distortion against that template, and using psychological skills to challenge the distortion, but not to frighten the patient off,' They draw on their psychological approach to help them evaluate treatments, and may sometimes change them accordingly. For example, research into offending behaviour shows that a punitive confrontational approach doesn't work too well. 'You do have to challenge behaviour, but in a way that engages the patient and encourages the motivation to change.' His and Jennie's background knowledge means they can warn patients that things might get more difficult before they get easier. From the research on sex offenders they know that if a sex offender says about their crime, 'It just happened', that is unlikely to be true - these things are usually carefully planned.

There are limits to how far the objectivity of the psychological approach can go. Ged says, 'If you work with sex offenders, it's very difficult to also work with victims.' But, he says, 'If people ask why we work with sex offenders, it's because of the victims, to try and reduce the risk of reoffending.'

Sue Cavill is the Society's Press Officer.

Restrictions on Guns

After the Dunblane killings, Ged Bailes received a large number of phone calls from the media about guns, as he has a particular interest in hostage negotiation and police firearms training. His involvement began when a major counter-terrorist exercise was held locally, involving the police, government and the armed forces. The organisers wanted a psychologist to work with hostage negotiators, and Ged went along. He found the exercise fascinating, and after that read all that he could about this type of work. He has undergone the police training courses for firearms officers, VIP protection officers and hostage negotiators. This, coupled with his interest in aggression and violence, has given him particular insights into traumatic situations and stressful scenarios. He is occasionally called out by the police to incidents and has helped with hostage negotiation and critical incident stress debriefing, following traumatic incidents.

Of the Dunblane incident, and particularly of calls for psychometric tests for people who hold firearms, he says, 'This is a good example of what psychology can and cannot offer. There was no way we could have detected this man. Psychology and psychiatry can't do a personality test on everyone who is assessed for firearms, and even if you did, it wouldn't stand up in court that that person, because they've got a particular profile, is going to be a Thomas Hamilton ...'You also can't automatically assume that a person with a mental illness or a history of sexual offending is more likely to use firearm.'

He therefore believes that, 'Anything we can do to restrict the availability of guns is a good thing. I appreciate that it impinges on people's freedoms to d what they want - it may affect people's livelihoods - but I don't like the idea that we have a society where there’s lots of guns. To try and prevent burglaries we lock our windows and put up security lights, thus trying to put an external control on someone's behaviour and reduce the risks to ourselves. We are making it difficult for the person to commit the crime. I would see restrictions on the access to, and availability of, firearms in a similar way.'

Regional Secure Units

There are 48 Regional Secure Units (or Medium Secure Units) in England, consisting of nine for people with learning disabilities, an 39 for people suffering from mental illness. The number of beds in them ranges from five to 90, although most fall within the range 15-30 beds. There are at present no units in Wales, although one is being built. In Scotland and Northern Ireland Carstairs Hospital provides both high security and medium security treatment for mentally disordered offenders.

The Norvic Clinic Forensic Unit is staffed by two forensic clinical psychologists, two consultant psychiatrists, two senior registrars and two junior doctors, a physiotherapist and a physiotherapist technician, two social workers, two occupational therapists, two occupational therapist technicians, more than 80 nurses and three part-time adult education tutors, as well as administrative and support staff. Source of information: The Department of Health.