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Bernadette Solomon Msc Applied Criminology Candidate No. 347175Word Count 15,982

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What factors influence & shapeprofessionals attitudes towards thementally ill: complexities and stigma

attached to working with forensic andgeneric mental health clients


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Acknowledgements

I would like to make the following acknowledgements of great thanks for all the words of

encouragement in helping me to realise my dream of undertaking this Msc course. I would

like to thank my husband David Solomon and my wonderful family, and also all my fellow

colleagues & tutors at Hertfordshire University including Terry Hagan for all their assistance

and support. In particular I would like to thank Susan Brookes f or her tireless support, advice

and encouragement for the duration of my studies.


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Contents

Appendices.................................................................4

Abstract......................................................................5

Introduction.............................................................. 6

Methodology.............................................................. .8

The concept of Stigmatisation...................................... 9

Previous Studies..........................................................10

The Media.................................... ...............................14

The Blame Culture........................ ...............................18

Team Conflicts and Differences..... ...............................22

Multi-disciplinary Cultures.............................. .............28

Risk Management -Impact & Work related stress........36

Working Practice .........................................................47

The Way Forward Practice Implications....................56

Conclusion....................................................... ............59

References..................................... ..............................62


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Appendices

Future Research Proposal...........................................................Appendix (1) .......74

Ethics Form University of Hertfordshire..................................Appendix (2).........89

Information Letter...................................... ................................Appendix (3).........90

Consent Form.............................................................................Appendix (4).........92

Interview Schedule.....................................................................Appendix (5)........93

Questionnaire...................................................... ......................Appendix (6).........94

Databases...................... ...................................... ......................Appendix (7)........104


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Abstract

There has been much documented evidence regarding the views and attitudes of public

opinion and the media towards those individuals with mental illness, in particular those who

have offended . However it is important to explore the attitudes of practitioners who

provide services for those with mental disorders to establish insight on how these attitudes

are shaped, and what impact attitudes have in contributing to stigma and discrimination

within current practice. The author has reviewed the literature pertaining to attitudes of

mental health professionals, and has thematically explored the possib le influences that may

contribute to negative and positive viewpoints. The findings were varied showing some

positive attitudes were present, however social distancing and acceptance of clients who

presented with more challenging diagnosis, behaviours and offending histories were

evidenced to evoke stigmatised attitudes, and subsequently less acceptance in gaining

access to mental health services. The review has highlighted the need for further research in

raising awareness of the need to improve attitudes in practitioners who work with both

generic and forensic clients, and to provide the necessary resources, training and support

for staff. This will hopefully enable the ongoing development of anti-discriminatory practice

within services aimed at those individuals who rely on professionals to advocate and

empower them on their recovery path from mental illness.


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Introduction

There have long been areas of concern surrounding inclusion of the Mentally Disordered

Offender (MDO) in healthcare settings. In particular focus upon managing and caring for

those that may be perceived as dangerous individuals , coupled with mental heal th

symptoms, may prove both challenging and demanding to front line professionals working

in mental health. The MDO presents with complex issues that may link their mental health

issues to offending behaviours, and that may present problematic to professi onals in

managing clients in a community setting.

There has been growing concern that MDO s are indeed not receiving an inclusive and

comparable service to what we can be best described as generic mentally ill clients

(Maden, 2007). There may be various reasons for the disparity in service provision, and this

dissertation will examine staff attitudes towards individuals with mental illness and

offending behaviours.

The focus or interplay between differences in attitudes within Community Mental Health

Team (CMHT) professionals towards MDO s and subsequent applied practice issues, may

contribute some interesting issues surrounding stereotyping, marginalisation or indeed

positive attitudes towards working with this client group. This may highlight the gaps within

the service provision, and it could generate knowledge to inform better practice and inter-

agency collaboration. It will be important also to explore role disparities and team agendas

within CMHT s, that possibly will cause concern when accepting forensic clients for referral

and care coordination under the Care Programme A pproach.


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Past studies have identified how both the general public and professionals hold both

negative and positive attitudes towards mental disorder. Within this piece of work there will

be an exploration of the factors which may shape practitioners attitudes towards

individuals with Mental Illness.

One of those factors may be the influence that the media has on the public and professional

bodies concerning attitudes that involve stereotyping, race and perceived levels of

dangerousness in the mentally ill. Furthermore, there will be an exploration of media

attitudes to violence and its link to dangerousness, and potential influence on the

perspective of professionals working with the mentally ill. Another theme investigated will

be the blame culture that is often raised by homicide inquiries and appears to be

predominantly directed towards practitioners. This will examine the potential impact upon

staff morale and the reinforcement of possible negative shaping of staff attitudes.

There are concerns regarding team conflicts and disparities in professional roles and how

this may impact on attitudes and practice. These issues will be critically examined and also

how working with challenging behaviours and difficult clients can impact greatly on work

place stress for practitioners. In addition there will be an exploration of the strategies

implemented by professionals when dealing with client groups perceived as problematic. In

relation to multi-disciplinary working cultures there will be examination of how health,

prison and probation services attempt to balance between public protection and

maintaining the practitioners therapeutic alliance with their client group.


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Another area of interest is the implementation and associative problems concerning

professionals in relation to risk management. The dissertation will highlight issues regarding,

risk assessment tools and risk form-filling exercises in relation to subsequent time pressures

and risk preoccupation for staff. Furthermore it will explore how managerial styles may have

influence on creating a negative impact on professionals within their work. This may create

stress and poor mental health in practitioners in relation to increased work pressures, and

how the impact on working practice will be discussed.

The best outcome for better practice will involve a greater degree of professional

collaboration between services and therefore there will be an emphasis on what strategies

may help practitioners to work more effectively within their areas of expertise and how this

may improve better working standards of care for all involved. Current shifts in professional

identities will be highlighted and the need for better resourcing and development within the

services will be discussed. There will be further examination on how best to combat stigma

and discriminatory attitudes towards both mental health clients and professionals within

the services. New strategies and policy developments on how best to implement best

practice for those with generic and forensic mental health issues will also be considered.

Methodology

This dissertation aims at exploring the evidence on the attitudes of practitioners who work

with generic and forensic clients who suffer from mental illness. In addition it investigates

the possible themes which may have contributed to shaping practitioners attitudes. The

author initially intended to conduct an empirical study on professionals attitudes towards

mentally disordered offenders within the community, which would have involved NHS


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professionals viewpoints. However this proved to be highly probl ematic in obtaining the

relevant ethical permission within the timescale available, therefore the research project

was abandoned in favour of a systematic review of the literature pertaining to professional

attitudes and complexities working with mentally ill clients. However the potential research

project that would point to future work and possible research can be found in Appendix 1.

To locate relevant studies and published articles in this particular area of interest, the

author identified these through a critical and systematic search of the following databases:

Applied social sciences index and abstracts (ASSIA) and PsychINFO and Informa Healthcare,

in addition search terms used included the following: mentally disordered offenders,

mental health professionals, stereotyping and discrimination, Stigma or Attitudes, Or Media,

mental illness and stigma and beliefs. Furthermore these relevant articles identified during

the search process, identified through the reference list , linked to find other relevant article

sources pertaining to the area of interest, which otherwise may have been omitted . By using

a systematic approach the author endeavoured to reduce the chance of biases within the

review, and furthermore enable the audience to peruse the thoroug hness and validity of the

literature explored.

The concept of stigmatisation

The contextual framework of stigmatising individuals is based on the human capacity to

form into social groups, and within groups, where differences are pronounced, this can le ad

to acceptance or rejection from the group (Bhugra & Leff, 1993). This is not only

discernable for those suffering from mental health issues, but within culture and race


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differences. Discrimination can lead to exclusion of certain individuals from soci ety, with

deprivation from gaining housing, health, education and social support, this can be explored

within the literature of Goffman (1991) where it identified the difference in interactions

between the normal and the discredited.

Many of the stigmatising strategies tend to establish the them and us principle, primarily

introduced by Foucault (1971). Foucault noted that social and physical exclusion of lepers in

the Middle Ages was widespread, and with the eventual eradication of leprosy, Foucault

suggested that madness, and the mentally ill then became the new excluded individuals. He

summarised that unreasonably mad individuals were institutionalised (known as The

Great Confinement ) and treated in an inhumane animal -like fashion, thus stigmatised these

individuals from normal society. Foucault highlighted that not only the mentally ill were

discriminated against, but argued that socially unaccepted individuals also included the

homeless, unemployed, the poor and the orphans of this time. Foucault suggested that

there was unequal power and discourse in society, and that those who hold power over

others may abuse or show discriminatory attitudes towards them. Within the research

regarding staff attitudes, the concept of discourse and power will be highlighted within the

context of social exclusion.

Previous Studies in this area

Relevant early studies have highlighted that many clients suffering from mental illness have

been marginalised. Nunnally s (1961) six year study of 400 Britis h individuals found that the

majority of participants held attitudes which included, fear, distrust and dislike towards


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mentally ill individuals. Similarly those clients who had been discharged from psychiatric

institutions, found that they were at a greater disadvantage as ex-mental health patients,

than ex-criminals, and had extreme difficulties faced when attempting to seek housing, jobs

and education (Rabkin, 1974). This would suggest that public attitudes are reflected in

mental health staffs difficulties in attitudes and stigma towards their clients, when

attempting to assist in their social re-integration to the community setting. Ahmed and

Vishwanathan s 1984 study, using the same scale as Nunnally (1961) showed only a slight

shift in attitude change towards those people with mental health. This again shows how

little times have changed, and the lack of impact of anti-stigma campaigns towards mental

illness.

The psychiatric profession, have however also shown poor attitudes towards mentally ill

people, and it could be said that the opinion in particular of the medical profession can at

times reflect societies viewpoints. Scott (1986) reported that within her study of 87 medical

students seconded to psychiatry, some showed some slight improvement in their attitude

towards mental illness. Nonetheless this failed to raise the profession of psychiatry as a first

choice in their options of career. This area of staff roles and their impact on role

expectations, cultural backgrounds and training, will contribute towards gaining critical

analysis and understanding, pertaining to the development of professional s attitudes

towards forensic clients and importantly towards care of these individuals.

A recent study by Nordt, Rossler and Lauber (2006), explor ed the interplay of mental health

professionals attitudes towards people with Schizophrenia and major depression.

Interestingly the survey compared the attitudes of mental health professionals with those of


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members of the public. A large sample of 1073 professionals and 1737 members of the

public looked at social distancing, stigma and knowledge. The results showed there was no

difference between professionals and the public in attitude in relation to stereotyping and

willingness to closely interact with mentally ill people.

These attitudes taken by professionals (in particular psychiatrists towards mentally

disordered offenders) may have an impact on team ownership of certain classifications of

client disorders (Buchanan, 2002). To date there is a p aucity of research in this particular

area. It is therefore of interest, the increasing numbers of mentally disordered offenders

requiring therapeutic interventions are rejected and deemed untreatable by psychiatry

(Cleary, Siegfried and Walter, 2002). The type of offending behaviours, antisocial or

personality disordered with psychopathic traits, may have led to these difficult to manage

clients being signposted from generic services to forensic services. Within this piece of

research, the area surrounding the shift towards rejection (therefore passing on clients

towards the Criminal Justice System) and the introduction of the revised Mental Health Act

(DH, 2008), which revised the diagnostic inclusion of personality disordered individuals, and

therefore ensuring these individuals could not be excluded from services, will be explored. It

has been recognised that the clinical implications for mentally disordered offenders had

been largely ignored by health, and it is now time for mental health professionals and

authorities to prioritise prison to community functionality for this group of people (Gunn,

2000).

There will be a focus upon the literature that challenges the perceptions of violence and

dangerousness linked to mental disorder (Monahan, 1992). In defining the term


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dangerousness Gunn (1982) explained that it was made up of three elements

destructiveness, prediction and fear, this highlights that perceptions of dangerousness can

be variable and highly subjective, with a common perception that mentally disordered

offenders present as a danger to others. However it has been argued that studies looking at

homicides committed in England and Wales between 1997 and 2005, found 10 per cent

(510 of 5,189) were by persons known to have mental health problems at the time of the

offence (Large, Smith & Swinson, 2008). Subsequent estimations have recognised , g iven the

current population of the UK those with mental disorder committing homicides are low, in

fact 50- 70 cases of homicides a year were recognised in 2009 by the National Confidential

Inquiry into Suicide and Homicides. This highlights how incomparable the statistical data

relates to the sensational media hype regarding the dangerousness and violence levels of

individuals with mental health problems to the public and community. There is however

overwhelming evidence that suggests that individuals with mental health problems are in

fact more of a danger to themselves, in terms of self harm and suicide in the UK (Hall,1998).

Over the years, with the introduction of community care, there has been a drive to provide

mentally disordered offenders with robust care and treatment, this was recommended

within the Reed report (1992) with emphasis on the duty of community services to provide

substantial care packages, and wherever possible divert MDOs away from the Criminal

Justice System. This has been again reiterated within the recent Bradley report (2009) that

MDOs deserve early assessment, prompt treatment, and should receive the least restrictive

care within community services without prejudice.


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Social inclusion should therefore be foremost in practitioner s goals when creating a risk

management plan for clients and supportive strategies should be undertaken to help the

client achieve these accordingly. However, in some cases service users may be unaware of

their own risk; this may raise dilemmas for both parties in terms of increasing stigma.

However risk must not be overstated or used to exclude the clients from services. This

emphasises the need for open and honest information sharing with the clients and carers,

and regular reassessment of ongoing risks, which may enable positive communication

where risk related issues are of concern (DH, 2007).

The Media

There are various influences and factors associated in how an individual s views and

attitudes are shaped throughout their lives, and undoubtedly the media plays a large role.

In addition to traditional media such as television and newspapers in this age of high

technological development media coverage has further developed by access to internet and

social networking sites. It may be noted that the media is a very powerful tool, and at times

may influence a negative reaction and quite commonly can provide often exaggerated and

sensationalised stories to the public.

Acts of violence or dangerous behaviour caused by individuals with psychiatric histories may

cause considerable response by the media. In particular the generating of fear and anxiety

associated with psychiatric disorder, offending behaviour and violence may affect the public

view, and may lead to a distorted view towards all mentally disordered offenders

(Buchanan, 2002). The public perception of individuals who have mental health problems,


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are generally focused towards an exaggerated level of violence and dangerousness, and the

distressing images the media has depicted of the rare incidences of attacks or killings

associated with mentally disordered offenders (MDOs) has been noted to have led to moral

panic and the shaping of stigmatised attitudes by the public (Cohen, 2002). However the

added dimension of race when included in the media portrayal of MDOs becomes an issue

of increasing public perceptions with increased negative stereotypes associated with fear

and danger. The associative result may create an image of dangerous black people

(Fernando, Ndegwa, and Wilson, 1998 p.74 ) These distorted views about mental illness and

race may have profound effects for all black individuals in society, but even more so for

those individuals who are suspected of offending, that couple d with a suspected mental

health issue, can lead to discrimination, poor health care, and dismissive staff attitudes

(Fernando, Ndegwa, and Wilson, 1998).

Therefore it clearly appears that the perceptions of dangerousness are fuelled by news and

media coverage, and the increasing portrayals of crimes involving mental health users are

prevalent and exaggerated in content (Green, 2009). This has been highlighted during

analysis of media coverage associated with mental illness (Philo, Secker & Platt, 1994). This

showed that violence to others had received most attention, and had outnumbered more

sympathetic images of mental health issues. Research using focus groups confirmed that

the participants were strongly influenced by media coverage, and this linked t o attitudinal

changes towards mental illness (Green, 2009). Indeed in the United States of America during

the 1950s, the influence of media and its depiction of mental illness strongly emphasised

the unusual and bizarre symptoms of mental illness (Nunnally, 1961).


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A recent review of literature however, did not support the media portrayal of links between

mental illness and levels of dangerousness given to the public. A review showed only a weak

link between the two, which highlights the disparity between the public perceptions which

were that a strong link exists between mental illness and dangerousness (Corrigan &

Cooper, 2005). Consequently, this has led to much debate amongst mental health

researchers and the practitioners, regarding how much media accounts may affect mental

health staff attitudes towards MDOs. It has been stressed that social distancing and

stereotyping of mental illness, was comparable between the public and mental health

professionals and interestingly highlighted little to no difference between professionals

and the public in their attitudes towards those individuals with mental illness (Nordt, Rossler

& Lauber, 2006). This may reflect negativity from professionals working with mental health

users within the study mentioned, however it may be noted that many variables within the

study may be highlighted. The study had a very low response rate from mental health

professionals, so indeed may not be fully representative of all staff attitudes. The

questionnaire used within the study was designed for the general public, and many of the

professionals deemed the ques tions and answers categories too narrow and vague.

Interestingly there was a 5 year gap between the public and professional surveys which may

have influenced their attitudes. A relevant factor mentioned within this study, emphasised

that within the time period of 5 years there may well have been negative media reports in

Germany towards those with mental illness, which may have had an influential affect on the

formation of attitudes by professionals (Nordt et al., 2006).

Therefore the relationship between the roles of the media affecting professional s attitudes

cannot be ignored. It may be emphasised that all professional s are firstly human, with


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associative levels of fear, which may have been fuelled in a similar fashion as the public

who are subjected to the fear and crime media coverage . However it cannot be assumed

that cause and affect are overly influenced from such an association. It may be questioned

that individuals who have a propensity to anxiety and fear are particularly fascinated by

particular media stories as may be professionals with increased contact with the mentally ill

(Newburn, 2007). For example a newly qualified mental health professional commencing a

new job position within a forensic setting, may develop an exaggerated interest in media

reports that portray mental illness and associative violence. Therefore the professional may

be justified in taking more interest in media feedback than another more experienced

forensic trained professional (Robinson & Kettles, 2000 ).

However, the reality in practice for many mental health professionals working with the

mentally disordered offender population is far from safe and secure, whether based in

secure in- patient facilities or the community. The author within professional reflective

practice has experienced at times levels of aggression and violence towards herself and

colleagues from mental health clients within her practice, and therefore it may be

emphasised that the correlation of mental illness and violence must be acknowledged. It has

been heightened that the incidence of mental illness amongst individuals remanded for

violence is relatively high, with a finding of psychosis in 11% who had committed an offence

of homicide, and a further 9% for other violent offences (Taylor & Gunn, 1994). Indeed a

more recent finding, highlighted within the UK700 study, found that physical assaults had

been committed by 20% of mental health clients over a 2 year period towards staff, and

60% of clients had behaved violently over the same period of time (Walsh, Gilvarry &

Samele, 2001).


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Therefore expectations and predictions of dangerous behaviours need to be realistic in

practice. It often occurs that some risk assessments are set to an impossibly high standard,

and when an incident of violence occurs, it deems the entire risk assessment as a failure,

with an unfortunate emphasis upon blaming the professionals involved in the risk formation

process. This may subsequently lead to negative attitudes towards mental health clients,

and also towards the management structure within the service (Maden, 2007).

The Blame Culture

Mental health services have been increasingly feeling under pressure regarding homicide

inquiries that have taken place over the past years (Appleby., Shaw., Sheratt et al., 2001).

Consequently concern has grown as a result of public and political interest regarding the risk

elements associated with individuals with mental illness (Szmukler, 2000).

The case of the murder of Jonathon Zito in 1992, by a former psychiatric client Christopher

Clunis, led to a lengthy formal inquiry into the care and treatment of the client, the

circumstances of the homicide, and in particular the clients relationship with mental health

services. This inquiry led to widespread criticism of staff and placed the onus of blame

heavily upon mental health services (Ritchie, Dick & Lingham, 1994). Similarly other inquiries

have also negatively highlighted mental health services throughout the years. In the case of

Michael Stone, an individual who had been diagnosed with a personality disorder, and who

committed a double homicide, there was again areas of blame attributed to his community

mental health nurse, as prior to the attacks, he had divulged that he had fantasised about

killing (DH, 2006). Indeed comparatively, in the child abuse case and eventual death of


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Victoria Climbie (House of Commons, 2003), the inquiry and media focused upon the

negligence of Victoria s social worker involved in her case (DH, 2002). The inquiries were

critical of services and tended to emphasise individuals for scapegoating . Indeed some of

the inquiries highlighted shocking deficits in care and management of MDOs, however it

may be argued that these mistakes may not be attributed to individual staff members, but a

much wider systemic failure of an under resourced service, where emphasis has lay on

service deemed priorities rather than on risk management and violence prevention

strategies (DH & Home Office, 1992). It may be noted therefore that the impact of a

homicide by a client with mental illness, may have devastating implications, not only for the

victim and their families, but also for the professionals involved (Maden, 2007).

In particular Psychiatrists have become targets for blame and accusations following a

homicide committed by a mentally disordered offender, and wh ilst accountability is

rightfully pertinent within professional practice, the effects of this blame culture may be

counterproductive, and it may lead to risk aversive and defensive practice. Indeed instead of

creating better and safer practice, it appears to have had a negative impact upon mental

health professionals, practice, mental health clients and the public (RCP, 2008).

In consequence, the level of low morale, feelings of fear and anger, and subsequent

recruitment problems may have an impact upon services (RCP, 2008). Therefore by

damaging staff morale, through unfair criticism of individual practitioners, and in the

process failing to raise and identify the gaps and underlying factors, professionals have

been left within forensic psychiatry to feel vulnerable and unsupported in their work. This

may lead to a negative attitudinal stance for practitioners working with offenders, and the

damage to morale may also have impact for other practitioners and colleagues, who may be


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adversely affected by the knowledge that they could find themselves in a similar situation in

the future (Maden, 2007).

Szmukler (2000) supported this view, and emphasised that homicide inquiries had

reinforced stigmatised attitudes towards mentally disordered offenders, labelling them as

The dangerous lunatic (Szmukler, 2000, pp.6 ) This also contributed to the public fearing

the mentally ill, and Szmukler argued that this may subsequently have led to public

confidence in services being undermined. Subsequently mental health services were

humiliated through the process, which led to staff resigning and loss of confidence in their

roles. In particular it highlighted that the area of community psychiatry was the area most

depleted of staff, particularly in the inner London area. Consequently the emphasis for

remaining staff working with MDOs became obsessive towards increased risk management,

some clients of whom it could be argued had not been formally diagnosed as suffering from

a mental disorder, and this may have inadvertently caused generic clients to suffer from lack

of attention and care from community mental health professionals. Once more this may

have impacted upon professional s attitudes causing feelings of resentment and negative

attitudes towards forensic clients, with the increasing emphasis on the professional to

become more coercive towards the client, with the overuse of compulsory admissions, and

feeling less of a caring professional, and more like a social control agent (Szmukler, 2000).

However, the eagerness displayed by community mental health teams (CMHT) in their

opposition to compulsory community treatment orders may be comparatively explored. It

may be argued that they are either overly concerned for their client s human and civil rights,

or given the ongoing anxieties regarding the current culture of individual blame shifting, it

may be reasoned that they are understandably worried about accountability issues, and for


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their personal responsibility regarding the behaviours of some risky and on occasion

unpredictable behaviours displayed by the mentally disordered offenders client group

(Buchanan, 2002).

Using reflective practice the author has noted that CMHTs are usually uncomfortable with

care-coordination responsibility of MDOs who display what may be perceived high risk,

offending behaviours, sexual offending and dual diagnosis clients. It has been regularly

voiced within the CMHT that lack of resources and high caseloads have caused concern

(SCMH, 2007). In addition the increasing pressure for staff directed through NHS

management and policy directive, with aims to meet national standards and targets, has

further inflicted more stress and therefore may lead to staff to increasingly avoidant

behaviours. Therefore it is not uncommon practice for CMHTs to employ deflection

methods to justify rejection of MDO clients. As previously suggested, due to a variety of

reasons, which will be explored further on within this piece of work, it seems to suggest that

discrimination for this client group begins within the mental health system (Sayce, 2000).

Therefore it has been suggested that there is a need to move away from overemphasis on

blaming an individual practitioner and look towards systemic explanations in the future.

Such identification has been introduced by the National Health Service (NHS) by the

adoption of Root Cause Analysis whenever serious and un toward incidences occur within

their service. This has been evidenced as a better and more systemic model that examines

the underlying causes for serious incidences, and moves away from individualised shaming

of individuals (Maden, 2007). The apparent shift towards the health service adopting an

emphasis on systems and management factors, rather than particular individual


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professional s failings, is no doubt a positive factor for mental health professionals in

practice. It has been raised that this approach may be more useful if inquiries in the future

viewed the individual s error as a symptom rather than a cause within the process (Munro,

2004). As services develop in this way, staff attitudes may shift for the better, as no doubt

staff morale and confidence will enable a more open and honest exchange regarding

potential anxieties working and may divert avoidable errors in the future when working with

a challenging client group.

Team Conflicts and Differences

The inclusion of mentally disordered offenders within mental health services has been

raised as one fraught with difficulties, therefore the importance of practitioners working

cohesively is paramount to access and treatment for this particular client group.

Team conflicts may have an overall impact on the shaping of attitudes, and have impact

upon service provision for mentally ill individuals.

Community mental health teams (CMHTs) are viewed as the focus of community care,

whereby newer and specialist services are developed around existing community services

(DH, 2002). Their client focus is predominantly those individuals suffering from severe and

enduring mental health problems (e.g. schizophrenia) Professionals offer a range of

interventions, including both short term and continuing treatment, care and monitoring.

CMHTs are recommended to also care co-ordinate up to 35 clients, and within a team a

maximum caseload for the team as a whole of 300 -350 mental health clients (SCMH, 2007).

Comparatively, Forensic mental health services engage therapeutically with clients who are

at the interface of law and mental health services. Practitioners within this specialist area


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offer assessment, treatment and management of mentally disordered offenders. In addition

this client group may have offences linked to sexual offending behaviours, Anti Social

Personality Disorder, and some individuals that suffer from severe and enduring mental

health issues. However those same clients may be at risk of, or indeed have, committed

serious offences (SCMH, 2007).

It may be recognised that there are areas of disparity within the roles of CMHTs and

forensic services, in particular concerning the typology of client diagnostic grouping and

offending histories (Robinson & Kettles, 2000). However, there have been few studies into

what constitutes the role of the forensic practitioner, and whilst there appears to be conflict

between the role of the community mental health practitioner and that of the forensic

practitioner, what does seem evident is that the practice within mental health services is

becoming increasingly predisposed by the forensic and legislative framework of mental

health care (Robinson & Kettles, 2000). In addition, it may be noted that most mentally ill

homicides occur in general psychiatry, and this simply reflects that most clients are treated

by generic CMHTs, identifying a need for CMHTs to re-evaluate service acceptance towards

MDOs needs within community services (Maden, 2007).

It is therefore of importance to identify possible reasons for the seemingly reluctance of

CMHT practitioners to work with MDOs. It has been recognised that CMHT staff suffer a

high degree of workplace stress, and evidence has shown that the MDO client will add a

disproportional stress factor; therefore this may lead to reinforcing negative staff attitudes

towards working with MDOs. The accountability and care of these type of individuals, fear

of violence and client relapses were in particular stressors clearly identified by community


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staff members. In addition time demands contributed to stress in staff member in relation

to non client aspects of service pressures (Reid, Johnson & Morant, 1999). Additionally,

some inexperienced newly qualified professionals are being expected to manage highly

complex clinical forensic cases, working in isolation, without robust or adequate training and

supervision (Buchanan, 2002).

The author within reflective practice has noted, over the past 20 years, a steady shift in

community employment strategies. The employment within the NHS of newly qualified

professionals were then required, upon completion of their studies, to gain their initial

experience as staff nurses working on in-patient ward facilities. This would have gently

introduced new staff into their new roles. The environment of the ward, experienced

available staff, and robust mentoring may have assisted the individual to gain confidence in

making autonomous decisions (Charnley, 1999). However, recent practice indicates there

are no such precautions in place, and consequently within CMHTs, newly qualified

registered mental health nurses are commonly seen practicing. Indeed stress related illness

in staff may be linked to recruitment difficulties, and place further ongoing pressure upon

staff and management to respond accordingly to service need. Indeed recent years have

witnessed numerous changes in the structure of the NHS in England and Wales in

prioritising services and in the changing role of nurses (Mc Vicar, 2003). It is therefore less

than surprising that the newly qualified nurse may be distressed, anxious and resentful at

being directed to care coordinate a complex forensic case. The stress experienced by the

practitioner relates both to the individuals perception of the demands being forced upon

them, and equally to their perception of their capability to meet those requirements (Mc


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Vicar, 2003). Furthermore it has been highlighted that newly qualified nurses have

acknowledged suffering from work related stress, in particular suffering from low

confidence levels regarding their clinical skills (Brown & Edelmann, 2000). This may suggest

a revision by mental health services concerning training and induction of new staff, with

emphasis upon supporting individuals particularly within the area of community mental

health services.

Stigmatised attitudes by professionals towards forensic clients may take the form of many

guises within mental health services, therefore when CMHTs are faced with high caseloads,

and increasing demands on their services, health care professionals may implement

strategies to deter forensic referral uptake within their team (New, 1996). These strategies

may include the use of deterrence which may be characterised by staff appearing unfriendly,

offering inconvenient appointment to clients, overly stringent gate-keeping methods, bad

quality environments, and extending the length of time between appointments. In addition,

the use of deflection methods may be used by staff to discriminate against those with

mental health issues. Typically this would be where the referrals would be passed to other

agencies, passing from generic mental health to forensic services, and then possibly to

learning disability services, therefore avoiding any requisite to actually address the clients

need. Furthermore, dilution is another strategy which may adopt poor standards of care

towards the client, and reducing service provision. Further strategies are that of delays,

which uses waiting lists for clients, and denial , which would deny the client access to the

service altogether, for what may be seen as justifiable team reasons (Holloway, 2002,

Chap.10).


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Therefore, those MDO clients perceived as less desirable are likely to experience some of

these pragmatic strategies by professionals when referred to a CMHT for treatment. Similar

conduct may also occur within forensic mental health services, which may be more selective

in accepting cases that are deemed acceptable for taking responsibility. There is a growing

concern that this type of discrimination may affect and reinforce negative views by

professionals in accepting the role of care coordinators for MDOs, and therefore service

managers need to increase awareness of such avoidant strategies, ensuring that the MDO at

the very least may be treated with fairness within the referral scheme, and hopefully move

away hostile and rejecting staff attitudes (Buchanan, 2002).

There is growing evidence to suggest that mental health professionals show stigmatising

attitudes towards MDOs and in particular towards those clients with a diagnosis of

personality disorder (James & Cowman, 2007) . Clients with personality disorder can behave

in ways that may inadvertently invite rejection from professionals, at ti mes being hostile

and demanding (NIMHE, 2003). They may also show tendencies to sabotage attempts at

help by professionals. These types of behaviours may lead rejection and negative attitudes

by staff towards those clients who have a diagnosis of personality disorder (James &

Cowman, 2007). This has been evidenced within the literature that attitudes of

professionals towards those clients suffering from borderline personality disorder (BPD)

were not favourable. In one particular study it showed that in a sample of 240 psychiatrists

in the United Kingdom, that their attitudes towards clients with BPD led to a more critical

attitude towards the client, than those not diagnosed with the disorder (Lewis & Appleby,

1988). Similarly nurses were found to less empathetic, more condescending in manner,

show belittling responses, and generally were more contradictory in verbal responses


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towards those clients with BPD than other clients not diagnosed with BPD (Fraser & Gallop,

1993). Additionally a study of psychiatric nurse s attitudes towards clients with BPD showe d

that some nurses viewed these types of clients as particularly difficult to manage, and used

language such as evil and monsters when referring to this client group. However the

most positive nurse attitudes were shown to be staff members that were predominantly

young, often in senior nursing positions, and were female (Bowers, 2002).

Another group of individuals who may be seen to challenge professionals personal feelings

and provoke an intense response is sexual offenders within mental health services. Indeed

this area of specialism may often be seen by CMHTs as one of the most challenging areas,

and they may feel overwhelmed, undertrained, and view the offender as evil and

condemn the individual rather than attempt to treat or rehabilitate the client (Houston &

Galloway, 2008). Within the prison services the construction of the sexual offender is

comparable with popular negative stereotypes. These offenders were not viewed as

mentally disordered offenders by officers, but as criminals .Therefore the label of mental

illness was rejected as inappropriate due to the perception that this type of offender knew

what they were doing , and there was a perception that sexual offenders should be

accountable for their actions (Mason, Carlisle & Watkins et al., 2001). The discrimination

against sex offenders by CMHT professionals may also be present; often professionals may

at times have difficulties working in a collaborative way with these individuals, often raisin g

concerns that certain professionals would rather not know the details of the offence as this

may further increase their feelings of rejection towards the client (Winnicott, 1947).


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Additionally most generic and forensic practitioners have intense direct client contact with

these challenging individuals, and this may lead to the practitioner suffering from

overwhelming emotional burden, and as a consequence, may potentially suffer from

mental fatigue or burn-out that may occur over a period of time, particularly for those

practitioners working with forensic clients (Freudenberger, 1974). However the impact that

excessive stress or burnout symptoms on practitioners and its affect on practice will be

further explored later on within this piece of work. An additional stress for practitioners may

be the experience of having to deal with the unconscious re-enactment of interpersonal

associations, (i.e. Transference) directly related to working with forensic clients (Winnicott,

1947). This may have some negative impact upon the practitioner s mood, the effect of

facing negative work environments, and also the potentially negative impact of frequently

having to listen to both unpleasant and violent scenarios (Robinson & Kettles, 2000). These

factors may have the potential for professionals to experience anxiety, and subsequently

create self defence mechanisms that may include social distancing from mentally disordered

offenders, which may lead to loss of contact with their clients (Menzies Lyth, 1960) .

Multi-disciplinary Cultures

The mentally disordered offender may present CMHTs with conflicts of duty within their

services. The common traditional role of the practitioner may be compromised by many

factors including, the intervention of coercion and compulsory treatment for their clients

and the expectation to engage actively with the criminal justice system (Buchanan, 2002).

A major change for mental health in the last decade has been the transfer of commissioning

responsibility for prison health care services to the National Health Service (NHS) .


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Consequently prison in-reach mental health services are based upon the community

mental health team model. This has been seen as a positive shift for equivalence of access,

quality and treatment of care for MDOs with the focus upon the continuity of care between

the prison and community services (SCMH, 2008a). Subsequently this has presented a new

optimistic opportunity for a positive shift in culture and attitude within the prison and

mental health community services. This particular service development has been positively

received by the NHS and the public, and has been speculated to have increased better

collaborative working practices between mental and prison mental health workers in

prisons (Rutherford, 2010). There is evidence to support that attitudes are correlated to

familiarity with mental illness and those who have increased contact with mental health

clients are reported to hold less prejudicial views and attitudes towards them(Corrigan,

Edwards & Green et al., 2001b) . Consequently, it may be argued that the increased contact

for CMHT professionals working with offenders, may lead to less discrimination in practice

(Corrigan et al., 2001b).

However, there remain areas of disparity between prison and hospital/community

professionals. The principal purpose of prison is punishment, deterrence, and a strong

element of social control. Similarly forensic secure units also manage offenders within a

context of social control; however it may be argued, that the forensic service has a primary

focus of treatment and rehabilitation (Rutherford, 2010). Within a recent review of the

prison health care and in-reach services, it has been reported that there is an increased

tendency to medicalise the more challenging of offenders by prison health staff (Durcan,

2008). The review found that few staff had any mental health training; this included some

health staff displaying unrealistic expectations regarding the capacity of the prison in-reach


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services, suggesting that prison mental in- reach staff should take full responsibility for all

prisoners with mental health problems .

The relationship between the NHS and the Prison Service has been a challenging area, as

both services approach their practice from different ideologies (SCMH, 2006). The majority

of prison in-reach staff found that the level of security in a prison environment was

prioritised over the health needs of MDOs, which led to poor attendance in clinics due to

security arrangements. This consequently may prove detrimental to clients care,

furthermore denying mentally ill offenders access to the health care and treatments they

deserve. Therefore there has been an exacerbation of dissatisfaction within the two

cultures, which may lead to less than satisfactory communications between the priso n and

health staff. This may have a negative impact upon professionals attitudes towards others

roles and practice (SCMH, 2006). These conflicting ideas may lead to failure to adhere to the

recommendations within the National Standards Framework, which encouraged positive

inter-agency working practices, integration and exchange of skills between all professional

groups (DH, 1999). Additionally, mental health prison in-reach teams tend to focus their

attention upon offenders suffering from severe and endur ing mental illnesses (SMI), which

is vague in its terminology and interpretation, which may discriminate and exclude those

MDOs which suffer from mild to moderate mental health problems.

The prevalence of poor mental health among young people within the prison system has

been evidenced as 95% (with at least one mental health issue), and over 80% suffer from

two or more mental health problems (Lader, Singleton & Meltzer, 2000). This highlights that

there is little input available for those with young people who have less serious mental


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health issues within the prison system, despite the fact that these individuals have been

raised as a high risk of self harm and subsequently are evidenced to be up to 18 times more

likely to commit suicide as those in the community (Prison Reform Trust, 2006). Therefore it

may be argued, that vulnerable young individuals are being ignored and discriminated

against in gaining access for care, which may have serious implications and have a negative

impact upon their mental health recovery.

Rickford (2003) found that due to short staffing levels , the over use of medication within the

prisons he reviewed had been used by some staff to manage problematic behaviours in

their mental health prisoners. If this is accurate representation, then it raises a human rights

issue, maybe suggesting that this method of containment is morally wrong. However if it is a

matter of increased mental illness exacerbated by imprisonment then this is an area that

needs further exploration and action (Rickford, 2003). The prison culture has at times been

viewed as rigid, and the term custom and practice has been used to depict professional

behaviour that has become routine or ingrained, characterised by repetitive

institutionalised behaviours (Durcan, 2008). The form of this behaviour has included the

common practice among prison health staff to frequently use the surname of the prisoner

when addressing individuals; this may indicate a method of depersonalising the prisoner. In

a recent review, the staff viewed this practice as acceptable, and viewed that the offender

should indeed earn the right to be addressed by their first name (Durcan, 2008).

A recent survey by The Sainsbury Centre for Mental Health (2009) highlighted the issues

surrounding early release for MDOs as a problematic. It raised the problem of unexpected

release for prisoners into the community, often without an organised plan of ongoing care.

This included, a lack of referral to community mental health services, no General


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Practitioner registration (which can also mean a rejection from mental health services),

accommodation problems, and poor liaison with community drug and alcohol services

(Durcan, 2008). The overall concept of multi-agency collaboration is an important

component of the government s philosophy, with emphasis upon the professions that are

involved in health, child social services, law enforcement, probation, housing and education.

The aim is to improve the service delivery and improve access for service users (Salmon,

2004).

However, the reality of multi-agency work presents its own challenges to professionals. It

has been highlighted that knowledge boundaries can be blurred, and staff identities

challenged as roles and work responsibilities shift accordingly (Robinson & Cottrell, 2005) .

Subsequently this may have some impact on professionals feeling frustration and anger that

may reflect in their face to face interactions with their clients (MDO) which may present as

self defence mechanisms, such as social distance and detachment behaviours (Corrigan et

al., 2001). Nevertheless, positive working practice has also been acknowledged,

demonstrating that different cultured professionals are increasingly striving to work

effectively together, through shared intentions, through respecting each other s roles and

diversity whilst acknowledging common team goals for MDOs in the community (Robinson

& Cottrell, 2005).

The Mental Health Treatment Requirement (MHTR) is an option available to court

sentencers when developing a community order or a suspended sentence order for an

offender who presents with mental health problems. If the offender consents to this

additional requirement, the subsequent MHTR requires the offender (MDO) to receive


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mental health treatment for a precise period (Seymour & Rutherford, 2008). Subsequently

many professionals hold varying views and attitudes towards the MHTR, which largely

depend upon the familiarity and confidence of the individual practitioner in utilising the

appropriate use of the requirement (Khanom, Samele & Rutherford, 2009). One main

concern of CMHTs, involved anxieties regarding how best to manage an offender, should

the client not attend their prescribed mental health appointments. This would be a breach

of their probation and requirement conditions, but perhaps more importantly it may

suggest non-compliance with treatment which could lead to the clients relapse in their

mental health (Khanom et al., 2009). During this particular study, 56 participants were

interviewed, ranging from court staff, probation, health, drug rehabilitation, forensic

practitioners and court diversion and liaison schemes. Subsequent role expectations for

practitioners caused concerns in regard to using the MHTR for offenders with mixed views

voiced by probation and court staff, regarding whether the MHTR should be used to aid the

re-engagement of clients back to services, or whether it should focus upon those individuals

that are first contact clients with mental health presentations. It was felt that this may have

some impact on reducing the likelihood of reoffending, in particularly should the mental

health problem correlate to the offence (SCMH, 2009).

Khanom et al., (2009) noted a lack of awareness of the MHTR notably by health care

professionals, with some confusing the MHTR with the Community Treatment Order under

the Mental Health Act (MHA, 2007). There was a strong element of criticism by court staff

about the use of the MHTR, many of whom felt that mental health was not the business of

the criminal justice system (Khanom et al., 2009). This may cau se inter-professional conflicts

in the future regarding CMHT and forensic practitioners working with their clients,

considering the reluctance of court professionals to aid the transition of MDOs and their


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mental health issues through the judicial system. Similarly one psychiatrist within this study

also voiced negative attitudes towards the MHTR process, indicating that it was not the role

of mental health service s to police offenders on a MHTR within the community mental

health team s policy standards (Khanom et al., 2009). The relationship between probation

and mental health services continues to be problematic, and additional concerns have been

raised regarding information sharing, confidentially issues, and maintaining contact

(Khanom et al., 2009). Psychiatrists were particularly unwilling at times to distribute

psychiatric reports to probation services. Contrastingly, most health professionals view very

little difficulties working alongside probation officers (Robinson & Cottrell, 2005). This

highlights that collaborative working practices are enhanced in cases where the perceived

higher risk offenders are involved, in particular those individuals who are subject to

stringent discussion and management procedures by probation services, under the multi -

agency public protection arrangements (MAPPA).

The National Service Framework for mental health (NSF-MH) was introduced in 1999 by the

Department of Health, it set out a 10 year plan of recommendations to improve standards in

mental health care in the United Kingdom (UK). The agenda recommended an increase in

recruitment of staff of at least 38%, and an additional emphasis on requiring an increase in

total spending on mental health services, which may have the potential to impact positively

on service delivery to all mental health users (DH, 1999). However, in a recent review of the

NSF-MH strategy, there was concern regarding the over ambitious plans of the 1999

agenda, pointedly arguing that the impact of expenditure growth rates and the recent

British recession, has undoubtedly left the National Health Service (NHS) struggling with

financial pressures, which may leave a shortfall on the original objectives prescribed by the


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NSF strategy within the planned timescale (Boardman & Parsonage, 2007). In addition, the

review suggested that extra costs will be involved on particular areas of need, which include

spending on atypical antipsychotic medication, computerised psychological tr eatments and

inpatient mental health units. Additionally the UK s diverse population; including asylum

seekers and the increasing use of illicit substances in MDO clients, coupled with a high

demand for additional forensic care, arguably may have the potential to increase the

pressure on mental health professionals in caring for this vulnerable client group (Boardman

& Parsonage, 2007).

Consequently there has been an increased emphasis on reaching targets and the

introduction of benchmarking standards for professionals has been prolific in recent years.

These introduced targets demand that staff demonstrate to line managers how they attain

best practice for their client group within mental health services (DH, 2005 b).

This may prove somewhat of a challenge to CMHT and forensic mental health professionals,

taking into consideration that in the UK at present, CMHT s will expect to receive over 3,591

newly referred clients to their service each year (Boardman & Parsonage, 2007).

Comparably figures have indicated that forensic services have a high level of unmet need for

which forensic services are inadequately prepared (Boardman & Parsonage, 2007).

Arguably the additional pressure and impact on staff will undoubtedly increase, with the

implications of the amended Mental Health Act ( DH, 2008), the Criminal Justice Act (Home

Office, 2003), where emphasis has been on protecting the public against violence associated

with individuals suffering from severe and dangerous personality disorder (DSPD) and the

practical management of those with personality disorder (Livesley, 2003), have

subsequently demanded the use of actuarial risk and auditing tools to be implemented by


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all professionals (Boardman & Parsonage, 2007). Therefore the extra work load presented to

front line staff, may lead to practitioners feeling overburdened, and often staff may be left

feeling that they are compromising standards of care for their clients, by the increasing

pressure by managers towards professionals to reach deadlines for auditing mental health

services. In the author s professional reflective practice, the matter regarding practitioners

struggling to balance the issues of caring for clients and completing audits and forms, has at

times led to staff voicing concerns that work pressures and negative attitudes towards

management and policy requirements , and may have led to less time and quality of care for

their clients (RCP, 2008).

Risk Management

There is growing concern that an over preoccupation with risk to others has dominated the

mental health and offender management field, particularly in England for some years (RCP,

2008). This is less than surprising, as the influence by many previous homicides,

independent inquiries and the increasing media interest has suggested a failing system, in

particular towards mental health professionals working with MDOs in a community setting

(Maden, 2007). However, the overemphasis of risk assessment and management by mental

health professionals may highlight area of disparity. The core function of risk assessment is

primarily to serve the purpose of improving care, and to encourage a culture of safe and

improved practice. Conversely, there appears to be evidence to suggest that risk assessment

may well have had a negative impact on professionals, in practice and interactions with

their clients and the public (RCP, 2008).


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There is however, the need to recognise that risk management of MDOs is a necessary and

integral component of mental health services. The function of CMHTs and forensic services,

are directed to safeguard the health of their clients and the potentia l risks that may occur to

others which may be due to the multiplicity and complexity of the links between mental

disorder, violence and offending risk behaviours (Monahan, 1992). There has been a notable

amount of evidence that concludes that an individual, who suffers from a mental disorder,

in particular from Schizophrenia, presents as an increased risk of committing an act of

violence in the community (Maden, 2007). This may be statistically comparable to the

association between smoking and lung cancer (Maden, 2004). Furthermore the stronger

correlation between personality disorder, psychopathy (Hare, 1996), drug and alcohol

misuse and violence further complicates the already arduous task for practitioners in their

practice (Lindqvist & Allebeck, 1990).

It may be highlighted that although risk assessing and management may help avoid or

reduce some risk behaviours, risk in itself cannot be eradicated fully, and accurate

prediction may not be possible for some MDOs within community services (RCP, 2008).

Nevertheless, the use of actuarial risk assessment tools may enable practitioners to gain a

more reasoned and accurate picture for individual cases within their practice (Hart, Michie

& Cooke, 2007). The importance of robust assessment of the MDO clients problems cannot

be emphasised enough, as there may be areas of complex clinically presentation, of an often

socially discriminated and chaotic offending lifestyle, may frequently cause huge concerns

and anxieties for those CMHT practitioners working with this type of individual (Buchanan,

2002). However areas that may need inclusion in the risk assessment and management of

clients may include not only the mental health state component, but also areas regarding

thoughts of self harming, homicidal ideation, substance misuse, interpersonal and


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relationship issues, financial and housing, employment status and educational and training

aspects of the individuals life (Buchanan, 2002). Additionally the strengths and weakness of

the client, and hope of recovery in client participation is a very important aspect within the

assessment, as with all other types of clients within mental health services, the MDO may

likely have suffered from practitioners choosing what and how to manage the risk of these

individuals without informed consent and full collaboration in the within the context of the

professional relationship during the assessment process. There is gro wing recognition of the

need to balance the issues of safety whilst achieving and encouraging positive risk taking

with mental health clients, and further training of staff has been actively encouraged in the

UK (DH, 2001). The evidence shows that up to 50% of staff are presently undertaking risk

assessment involving the clients in formulation of their own risk assessment (Shepherd,

Boardman & Burns, 2010).

However, a recent survey by the Royal College of Psychiatrists (2008) argued that

completion of risk assessments may provide professionals with a false sense of security that

the risk had been assessed, regardless of an evidence base. In addition out of the 1937

psychiatrist participants in this study, more than half the participants (58%) reported that

the use of such risk forms was used in a risk defensive organisational approach, this included

some emphasis on regime and methods used within a medical culture, and not as a robust

way of determining evidenced assessment of risk for the individual client (RCP, 2008).

Therefore, the growing tensions between using risk forms as a means for avoiding litigation

and blame, against the back drop of using risk forms to assist in judgement and risk

management is proving a common issue within many professions, which may lead to staff

attitudes pertaining towards a tick-box mentality within their practice. The over-use of


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form filling, and may lead to the potentially unsafe assumption that once the risk

assessment form had been completed that it may be forgotten about, with little effort to

engage in the ongoing assessment of risk for mental health clients (RCP, 2008).

The author has noticed frequently within practice situations, that the act of form filling

whilst in the presence of MDOs may lead to staff acting towards their clients in a detached

manner, losing themselves within the format of the form, rather than showing good eye-

contact, empathy or interest in the therapeutic communication with the client, which may

lead to the client feeling ignored, which subsequently may lead to damaging the ongoing

therapeutic trust relationship. In addition this may also create a state of anxiety for the

professional which may have further led to attitudes of detachment and social distancing

towards the client (Aiyegbusi & Clarke-Moore, 2009). Furthermore, the task of form filling

(with little collaboration with the client) by t he professional for the client, in it may foster

the attitude of benevolence, with the professional s viewpoint reinforcing stereotypical

assumptions that supports the view that those with mental disorder are incapable, weak,

and immature. These types of attitudes furthermore may have the potential to demonstrate

disrespect and pity towards the client, thus potentially leading to further stigmatisation and

discriminatory practices (Hinshaw, 2007).

The potential anxieties and challenges that professionals face is seemingly increasing when

risk assessing mental disordered clients; in particular MDOs may create a culture of

distorted perceptions of risk by CMHT practitioners. This furthermore fuels practitioner s

worries that when high risk areas in MDOs behaviours are highlighted, this may lead to

them having to struggle with the risks, without support or the resources r equired to enable


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them to practice effectively (Maden, 2007). However, the majority of generic mental health

services have a preoccupation with failure, but also in contrast most mental health care

professionals seem to remain professionally optimistic towards risk management for their

clients. This may potentially demonstrate an area of weakness within the service, albeit that

optimism is a useful tool within the context of the recovery process, but this must however

incorporate a robust and realistic assessment of risk, in particular when encountering the

risk management needed for caring for MDOs, as this is not an area where risk assessment

can be look upon lightly by practitioners due to the evidenced heightened risk between

offending and mental disorder (Monahan, 1992).

Probation services in the U.K are also struggling with the balance of time management,

urgent tasks and the challenges of reconciliation between caring for offenders, whilst

attempting to complete lengthy assessments of need. The area of prolonged time stress has

been highlighted as repressive for offender managers and has a negative impact for the

outcomes of successful practice (Nellis, 2002). This may lead to errors being made, and the

professionals practice being seriously compromised, which subsequently may threaten

probations contribution to public safety. There is growing evidence that probation

practitioners are prone to override low risk scores in actuarial risk assessing, by replacing

the score with a higher prediction score, this is known as the precautionary principle ,

where practitioners are inclined to act cautiously when completing risk assessments for

clients. In particular when probation practitioners are working with sexual offenders, the

over eagerness to rate sexual offenders as a high risk (even where there was evidence to

indicate a lower score), is understandable, given that practitioners are often pressured and

exposed to managerial and public criticism (Ansbro, 2010). In a risk adverse environment


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combined with ever increasing case loads it may be argued that public protection cannot

rest alone on highly stressed and overworked staff, and that managerial and policy decisions

are now urgently needed on how best to support staff in a safeguard the public in a

probation service faced with such difficulties (Nelli s, 2002).

Risk assessment is an integral part of mental health services, and for mental health

practitioners the completion of risk assessment proforma (RAP) may lead to attitudes

varying from hostile to acceptance (Godin, 2004). The overall assumption in risk form filling

by practitioners is one of ambivalence, and a belief that once it is completed then, that is

one more task finished. However it remains unclear in applied practice whether RAPs are a

reflection of clinical decision making processes, or merely function as a paper exercise to

sate policy and procedures requirements (Maden, 2003). A recent study by Hawley, Gale,

Sivakumaran & Littlechild (2010), looked that staff attitudes and time costs in risk

assessment in mental health. There methodology included distributing 300 questionnaires

to participants from Hertfordshire Mental Health Trust, asking participants attitudes and

experiences of completing RAPs. The findings showed that risk form filling on average just

below 2 % of professional time in completing RAPs, this potentially indicates that cost -

effectiveness may have some important consideration for future practice , as the estimated

time factor for staff engaging in risk form filling is not insignificant. In response to the

attitudinal aspect of the study, the general outcome reflected a positive view, as RAPs were

considered as useful tools. However one must consider that this response may be attributed

to some staff feeling duty bound and obliged to express positive attitudes on a matter that

incorporates a NHS Trust policy (RCP, 2008).


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An interesting find within the study, was the disparity of opinion between professional

groups: nurses who worked in in-patient services expressed very optimistic views regarding

risk assessing. Doctors were the least enthusiastic, and community mental health nurses

were rated in between the two other averages. It may be noted, however that nurses spent

considerably more than double the amount of time completing the RAPs tha n doctors, and

this raises the question regarding why then are nurses more positive in attitude towards

completing risk assessment tools than doctors? One may hypothesize that the nursing

culture encourages compliance and at times demands their professionals to follow policies

and procedures in accordance to their nursing code of conduct (Robinson & Kettles, 2000).

However the medical school culture supports a more critical approach, and doctors may be

better informed on statistical concepts, which may lead to a more guarded approach to the

validity of risk assessments than their nursing colleagues (Gale, Hawley & Sivakumaran,

2003). In addition a doctor s perspective regarding the client s treatment and management

may differ from a nurses, and concerns may include: diagnosis, medication adherence and

management, whereas the nurse may have greater concern on the clients safety, acute

presentation issues and the possibility of absconding on an in-patient setting (Hawley et al.,

2010).

However, some limitations regarding the study must be emphasised. It is worth noting that

forensic mental health services were not included in this piece of research, as the

researchers of the study deemed that forensic services were not the core-business of

general mental health services. In the author s reflections in regards to professional

practice, it is felt that there is even greater need for forensic mental health practitioners

views on risk issues to be heard, as an increasing number of MDOs are now being cared for


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in generic settings. Therefore it may be advantageous for future research in exploring areas

of disparity or commonality, that may direct a clearer picture of how best to shape new risk

assessments , and complement better risk management procedures for best practice

working with MDO and generic mental health clients (Maden, 2007).

The rigorous processes that practitioners face when managing the risk of challenging MDOs,

and the increasing demands from their managers may have led to clinician s attitudes being

guarded and fearful of making decisions on risk, and moving away from embracing risk

assessment. The fear of litigation and the ad-hoc untested risk assessments have further

reinforced reluctance for practitioners to work with who offe nd and who suffer from mental

health issues. Furthermore, the use of local risk assessment tools that have been designed

by local mental health trusts, have been highlighted as variable in content and quality within

many areas of mental health, which may impact upon the practitioners skills of

interpretation and knowledge base in completing them to the highest quality that one

would hope for in practice (Higgins, Watts and Bindman, 2005). Therefore the

recommendations that have been highlighted by the Department of Health s B est Practice in

Managing Risk (2007), strongly suggest that risk assessment tools need to be designed on

evidence based principles, and that mental health trusts are advised to move away from

tick box risk tools, which do not have any research based evidence of value, that may

ultimately lead practitioners to engage in bad practice methods for their clients (RCP, 2008) .

However there appears not to be unfortunately any indication statistically that services will

not have to deal with the increasing pressures to reduce offending and risk of violence

working with MDOs , and therefore it is of importance that this may be acknowledged by


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mental health services, and provide the necessary support and training for practitioners

accordingly (Hinshaw, 2007).

In consequence it is hardly surprising that many practitioners who work with challenging

individuals suffer at times from increased work related stress symptoms, which

unfortunately appears to be inherent part of working within mental healt h services

(Hinshaw, 2007). The term commonly used for this particular stress is known as burnout

which is caused by excessive strain and psychological exhaustion (Maslach & Jackson, 1981) .

The symptoms of burnout may include, emotional exhaustion, over fatigue, feelings of

depersonalisation, and feeling ineffective as a practitioner. It is however important to

highlight the potential of these symptoms to impact on practitioners attitudes and views to

their work, and in addition how burnout can adversely affect a practitioners relationship

with mental health clients, offenders and MDOs (Maslach & Jackson, 1981).

A recent study in the correctional services in the United States of America ( USA) highlighted

the negative effects of symptoms of burnout on staff working with offenders. The

researchers examined the impact and consequences of burnout by questioning 160

correctional staff at a maximum security facility (Lambert, Hogan & Altheimer, 2010). The

findings showed that the effects of depersonalisation led to staff treating offenders

impersonally and even established that burnout symptoms may lead to callous and unkind

behaviours to offenders. It also indicated that staff admitted that they were also reluctant

to interact with offenders. Subsequently staff related that this led to them feeling

ineffective an

last one dissertation

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