Am I there yet? The views of people with learning disability on forensic community rehabilitation
| Published date | 14 December 2015 |
| Pages | 148-164 |
| DOI | https://doi.org/10.1108/JIDOB-08-2015-0024 |
| Date | 14 December 2015 |
| Author | Alana Davis,Michael Doyle,Ethel Quayle,Suzanne O'Rourke |
| Subject Matter | Health & social care,Learning & intellectual disabilities,Offending behaviour |
Am I there yet? The views of people
with learning disability on forensic
community rehabilitation
Alana Davis, Michael Doyle, Ethel Quayle and Suzanne O’Rourke
Dr Alana Davis is Clinical
Psychologist at Willow Service,
NHS Lothian, Edinburgh, UK.
Dr Michael Doyle is Forensic
Psychologist at the Department
of Psychology, Lynebank
Hospital, Dunfermline, UK.
Dr Ethel Quayle and
Dr Suzanne O'Rourke,
both are based at the
Department of Clinical
Psychology, University of
Edinburgh, Edinburgh, UK.
Abstract
Purpose –Previously, diversion from the criminal justice system for people with learning disability (LD) and
serious forensic needs in Scotland meant hospitalisation. More recently new legislation has meant that
community-based rehabilitation is possible for this group. The purpose of this paper is to qualitatively explore
the views of people with LD subject to these legal orders. This is both a chance to work in partnership to
improve services and also to make the voices of this potentially vulnerable group heard.
Design/methodology/approach –Semi-structured interviews were conducted with ten participants
subject to a community-based order. All participants were male. Ages, index behaviour, and time spent on
order varied. The data was transcribed and analysed using interpretative phenomenological analysis.
Findings –The main themes which emerged from the data were a taste of freedom, not being in control,
getting control back, loneliness, and feeling like a service user. Participants described positives about
community-based rehabilitation but also a number of negatives.
Practical implications –Participant accounts suggest that the current community rehabilitation model has
some shortcomings which need to be addressed. Suggestions are made for improvements to the current
model relating to: achieving clarity over the role of support staff and pathways out of the system; increasing
opportunities for service users to voice concerns; empowering staff teams via extensive training and
supervision; and directly addressing internalised stigma to promote community integration.
Originality/value –This is the first piece of work evaluating compulsory community forensic care for people
with LD from the perspective of service users. It highlights difficulties with the system which could lead to
helpful ways to evolve this model.
Keywords Offending, Community rehabilitation, Compulsory treatment order (CTO),
Interpretative phenomenological analysis (IPA), Learning disability (LD),
Paper type Research paper
Introduction
Although exact numbers are difficult to determine, people with learning disabilities (LD) make up a
small but distinct proportion of the offending population. Estimates vary but authors report LD in
up to a quarter of criminal justice samples (Barron et al., 2002). This is a significant proportion,
considering people with LD make up only around 2 per cent of the UK population (National
Health Service, 2015).
There is UK consensus that mentally disordered offenders (MDOs, a term referring to offenders
with serious mental health problems and/or LD) should be diverted from criminal justice systems
into rehabilitation via health and social care (Department of Health, 2009). For such people,
Received 28 August 2015
Revised 21 October 2015
Accepted 3 November 2015
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VOL. 6 NO. 3/4 2015, pp.148-164, © Emerald Group Publishing Limited, ISSN 2050-8824 DOI 10.1108/JIDOB-08-2015-0024
prison is highly unsuitable due to difficulties navigating and accessing parts of the system, as well
as their vulnerability when compared with other prisoners (Department of Health/Home Office,
1992; Scottish Executive, 2004). Previously the sole alternative for those with LD considered to
present an ongoing risk to the public was long-term hospitalisation within secure or LD units.
This has changed in the face of mass deinstitutionalization within generic LD services (Emerson
and Hatton, 1994). Over the last two decades moves to community care have resulted in
a significant reduction in inpatient beds in Scotland, meaning that hospitalisation for most people
with LD and forensic needs is no longer a viable option.
A report by the Scottish Executive (2004) (Home at Last?) recommended that agencies should
work with care providers to ensure appropriate community services were available for those
leaving hospital, in particular those with more complex needs, including the forensic population.
Mental health reform has also shaped this process. The Mental Health (Care and Treatment)
(Scotland) Act (MHA) (2003) recommended that those detained under the Act, such as MDOs,
should be subject to the least restrictive alternative, using community provisions where possible.
Designing community services
In designing a model of community-based care for serious offenders with LD in Scotland, a major
challenge was to construct services which allowed for the autonomy and inclusion outlined in
government policy (Scottish Executive, 2004; MHA, 2003) whilst still maintaining public safety.
In 1999 the NHS Management Executive (Scotland) outlined its policy on MDOs (NHS
Management Executive, 1999). The paper was clear that, although public safety was important,
the ethos of community care should be focused on meeting the needs of individuals and giving
them the best chance of being rehabilitated within society. The forensic managed care network
set up a working group in 2005, who were asked to establish guidance on how services for
forensic LD clients across Scotland should be set up. The recommendations are shown in Box 1.
The legal framework for compulsory community care was provided by the MHA (2003), which
introduced compulsory treatment orders (CTOs), and amended existing legislation to allow
similar orders (compulsion orders or COs) to be used where formal criminal charges had been
brought. Both types of order allow an individual to be returned to the community under a number
of conditions which may include: where they live; the professionals they must allow to visit them in
their home; and the treatment they must receive. In practice “treatment”is broadened beyond
medical intervention to include psychological interventions and acceptance of, often high, levels
of staff support.
Benefits of community-based rehabilitation
Community rehabilitation theoretically fits well with modern “strengths-based”approaches within
the field of forensic care (Purvis et al., 2011). One example of this is The Good Lives Model (GLM),
which advocates reducing recidivism indirectly by increasing an individual’s access to more
prosocial pathways to meet their needs (Ward and Brown, 2004). Community living, with its
Box 1: The principles on which the setup of forensic LD services should be based (Forensic Mental
Health services Managed Care Network, 2005, emphasis added)
■Development should focus mainly on the development of community provisions.
■Robust, flexible services are needed.
■Joint working is needed between social work, health, housing and social care providers.
■Specialist residential placements with high-standard accommodation allowing for close supervision
and monitoring is required.
■Specialist care providers should deliver care plans agreed by specialist multi-agency teams who
are set up to support these placements.
■There should be links between different levels of security including community services and with
other involved agencies –police, Criminal Justice, courts, prisons.
■Access to independent advocacy should be available.
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