Delivering Effective Psychological Therapies and Interventions in Forensic Mental Health Services
In 2023, in response to the Independent Forensic Mental Health Review, the Scottish Government published a new definition of a Forensic Mental Health.
“Forensic mental health services provide person-centred, safe and effective assessment; care and treatment; for persons with severe and disabling mental health disorders* who pose a risk of harm to others; and who have come to the attention of the criminal justice system (or whose behaviour poses a risk of such contact); in conditions of therapeutic safety and security in hospital (high, medium or low), or in the community and in criminal justice custody.”
*as defined in the Mental Health (Care and Treatment) (Scotland) Act 2003, whether or not they are, or may be, managed under its provision.
This definition underlines that forensic mental health encompasses more than secure care and that clinicians, including psychologists, work in a range of settings.
Psychological services within Forensic Mental Health are delivered in all levels of secure care, i.e., high, medium and low, and there are now more established Forensic Community Mental Health Teams (F-CMHTs), as well as applied psychologists and psychological therapists now working in mental health teams in prison. The largest population within Forensic Mental Health is still the adult male population, but some services are also specifically set up for adolescents, women and people with a learning disability. At the time of the initial publication of The Matrix: A Guide to Delivering Evidence Based Psychological Therapies and Interventions in Scotland (2011) a Forensic Matrix (2011) paper was published outlining best practice in delivering psychological therapies and interventions in Forensic Mental Health services. This paper does not replace the 2011 paper but rather is a supplement to it, in line with the change in the landscape.
Diversity and Complexity of the Population
In Scotland the Forensic Network conducts a forensic inpatient census. In 2024 the mean age of people in inpatient services was 43.9 years with an average stay of 4.3 years, although there are differences between high, medium and low secure services. The largest population of patients is in low secure settings (45.1%). The Census also looked at primary and secondary diagnosis using ICD-11 criteria. A primary diagnosis of schizophrenia was the most common (58.7%) while 11.2% of inpatients had a primary diagnosis of intellectual disability and 4.1% had a primary diagnosis of personality disorder. Of those inpatients with a secondary diagnosis, personality disorder was the most common (13.4%)
In addition to severe mental illness, exposure to adverse life events in childhood is common amongst forensic inpatients with 79.2% having experienced at least one of the 19 experiences that were assessed (Karatzias et al 2019). In this study which used data from the Scottish forensic inpatient census, a significant proportion of inpatients reported severe traumatic experiences, such as physical and sexual abuse as well as less extreme events. The authors further acknowledged that while childhood adversity played an important role in understanding the development of dysfunctional psychological and criminal outcomes, demographic and social-developmental factors are also important.
In a recent report on the mental health needs of Scotland’s prison population, it was highlighted that the prison population also experience complex mental health needs at a higher rate than in the community (McIntosh et al, 2022). Routine data is not collected, however based on quantitative modelling the report estimated 15% of the population were likely to have a long-term mental health condition, 17% were likely to have a history of self-harm, 30% were likely to have a current alcohol use disorder, 16% symptoms of anxiety and 18% symptoms of depression over the last week. In the 17th SPS Prisoner Survey (SPS, 2019a) individuals in prison self-reported having been assessed and diagnosed with mental disorder prior to coming into prison rat the following rates: depression 39%, anxiety/panic disorders 29%, post-traumatic stress disorder (PTSD) 11% and schizophrenia 4%, indicating high levels of need. McIntosh, Rees, Kelly, Howitt, Thomson et al (2022) note that the reasons for higher rates of mental health problems in the prison population are likely to be associated with a range of factors including higher rates of adverse life experiences, head injury and substance misuse, as well as a higher rates of experience of being in care, interpersonal victimisation and socioeconomic factors. It was also noted that the experience of being in prison can also be detrimental to mental health.
Engagement in Psychological Therapy
The above has a number of implications for psychological therapies. Firstly, although patients are in specific forensic services, they often have presenting problems that can be addressed through interventions that are non-forensic in nature and are the same as interventions delivered in non-forensic settings in line with recommendations in The Matrix. As some mental health symptoms can be a risk factor for future offending then the delivery of these therapies can address both clinical and forensic needs. Clinicians within forensic services, through the use of formulation, will have an understanding of when this is the case.
For some patients, those with a history of low educational attainment, head injury, or identified borderline learning disability or cognitive processing problems, there may need to be adaptations to therapy to accommodate this, similar to that outlined in other practice guides (see Matrix learning disability guidance)For patients who have little experience of interacting with healthcare and in particular mental health care and psychological interventions there may need to be a prolonged engagement period prior to the commencement of an intervention.
People being held in forensic environments may also be reluctant to engage in psychological therapies due to the nature of the environment and their understanding of the limits to confidentiality in these systems. As a result of the adverse life experiences they may have had, they are likely to have limited trust in others. All clinicians, including psychologist and psychological therapists, have a role in maintaining a secure environment. Patients will also be aware that therapists are likely to be called on to provide reports to those making decisions about progression or release. All of this often means there often a prolonged engagement period to facilitate the start of effective interventions.
Delivery of Psychological Therapies and Interventions in a Forensic Mental Health setting
The length of time a person has access to psychological services in forensic settings can vary greatly depending on the setting and order they are sentenced to/detained under and the individual needs of the person. Prior to the delivery of any psychological therapy, a psychological assessment will be undertaken. The timing of this will depend on a number of factors. The immediate point of admission is often inappropriate due to emotional instability, alcohol dependency/substance use, and/or acute presentation. The initial priority for many will be stabilisation alongside adjusting to the new environment.
Psychological therapies and intervention in Prison Settings
Since November 2011 the NHS has been responsible for providing health care in Scottish prisons. Patients in prison custody can access evidence-based psychological interventions, and mental health care, through the NHS mental health team in the prison. Mental health treatment in prison is therefore distinct from offending behaviour programmes provided by SPS for patients on long term sentences to support rehabilitation. The governance of psychological therapies lies within the governance structures of territorial health boards. The mental health needs of people living in custody may be identified on admission. However, this is often an inappropriate time to complete a comprehensive assessment due to for instance emotional instability, alcohol dependency, and /or ongoing substance use. The initial priority for many will be stabilisation alongside adjusting to the prison environment. Prisoners are not automatically referred to the mental health or psychological therapies team, and similar to the community, they would be referred on the basis of need. Enhanced and specialist psychological interventions will be offered where an assessment identifies this as appropriate.
For further information on compulsory orders and legislative framework please click here.
Psychological therapies and interventions in Secure Care
Following admission to a forensic mental health service there will be an assessment to identify needs. Within secure care, psychologists work within multidisciplinary teams (MDT) to consider all aspects of a persons’ care and treatment, the planning of progression through levels of security, the suspension of detention and other aspects of testing out, and discharge. As part of an MDT, there is an ongoing role in monitoring the wellbeing of the person and identifying any change in risk as well as delivery of psychological therapies and interventions to address specific needs.
For information on multi-disciplinary working and risk management please click here.
Within the MDT, psychologists have a responsibility to ensure consideration of psychological needs and the delivery of psychological assessment and intervention. This may focus on a range of needs including offending behaviour and mental health difficulties. Many of these needs can be addressed via psychological interventions and therapies aligned with The Matrix.
When working in Forensic Mental Health an assessment of risk of harm is paramount and this too will help to guide and inform interventions (see section on Risk). Psychologists in secure care will often deliver highly specialist tailored interventions, which draw from a range of psychological models, based on the needs identified in the psychological formulation. The sequencing of interventions will be determined by the formulation.
Where formulations indicate specific offending behaviour needs there are a range of programmes that aim to address thinking, attitudes and behaviour that might lead people to offend. These types of interventions can be delivered in a group format or on an individual basis and are designed to help people to develop skills which can lead to more pro-social life and reduce risk of harm. Many of the interventions will be based on cognitive behaviour principles as there is good evidence that this is most effective in reducing reoffending (please see Andrews & Bonta 2007, Transforming Rehabilitation: a summary of evidence on reducing reoffending for more information).
Forensic Community Mental Health Teams (F-CMHTs)
Many Health Boards now have Forensic CMHTs with psychologists forming part of the MDT. This supports the ongoing provision of psychological therapies and practice for patients or clients, many or all of whom have progressed from a secure or custodial setting into the community. In this context, psychological therapies are often to support clients with ongoing relapse prevention and recovery but also often providing input in response to crisis.
Important resources
Standards & Guidelines - RMA - Risk Management Authority
https://www.traumatransformation.scot/
NICE guidance e.g. Mental health of adults in contact with the clinical justice system? https://www.nice.org.uk/guidance/ng66/chapter/recommendations
Reference list
Forensic Matrix (2011) paper. Available at: https://forensicnetwork.scot.nhs.uk/publications/?tag_collection=matrix
Scottish Government (2023) Forensic Mental health definition Forensic Mental Health Definition
Scottish Prison Service (2019a) 17th Scottish Prison Service, Prisoner Survey. Available at: https://www.sps.gov.uk/Corporate/Publications/Publications.aspx
Gilling McIntosh, L., Rees, C., Kelly, C., Howitt, S., & Thomson, L. D. G. (2022). Understanding the Mental Health Needs of Scotland’s Prison Population. (Social Research Series). Scottish Government.
Forensic Network (2024) forensic inpatient census. Available at: https://forensicnetwork.scot.nhs.uk/wp-content/uploads/2025/09/Census-Paper-for-Web-2024-25.pdf
Karatzias, T., Shevlin, M., Pitcairn, J., , Thomson, L., Mahoney, A. & Hyland, P. Childhood adversity and psychosis in detained inpatients from medium to high secured units: Results from the Scottish census survey. Child Abuse and Neglect, 96, 104094. S0033291720004936jra 2794..2804
Andrews and Bonta 2007 Transforming Rehabilitation: a summary of evidence on reducing reoffending
Acknowledgements
Dr Katharine Russell, Dr Natasha Purcell, Dr Clare Maclean and Moira Scott on behalf of Heads of Forensic Psychology Services (HOFPS).