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ON THE BORDERLINE?
PEOPLE WITH LEARNING DISABILITIES AND/OR AUTISTIC SPECTRUM DISORDERS IN SECURE, FORENSIC AND OTHER SPECIALIST SETTINGS

CHAPTER FIVE PEOPLE IN SECURE SETTINGS: CHARACTERISTICS, HISTORIES, RISKS AND VULNERABILITIES

5.1 The following chapters outline the processes that impact upon the lives of people with learning disabilities and/or ASD in the different secure settings. This chapter sets these processes in context, describing the socio-demographic characteristics, past histories, risks and vulnerabilities of the sample of 49 individuals for whom case recording forms were completed.

SOCIO-DEMOGRAPHIC CHARACTERISTICS

Gender

5.2 All but 2 of the sample of 49 for whom case recording forms were completed were men. The exceptions were one girl in secure accommodation for children, and one woman in a prison setting. At the time of the study a further 4 women with learning disabilities were resident on the women's ward on the State Hospital site. Unfortunately completed case recording forms were not returned by this unit.

5.3 Given the issues around identification discussed in chapters 3 and 4, there may be more women both in Cornton Vale and the local prisons with capacity to accommodate women than have been formally diagnosed or assessed as having a learning disability and/or ASD. Women, however, comprise only a small (though increasing) proportion of all offenders (Scottish Office, 1998; Scottish Executive, 2002f; SPS, 2003). The prevalence of mild and severe learning disabilities and ASD is also higher among boys and men than girls and women (Foundation for People with Learning Disabilities, www.learningdisabilities.org.uk; PHIS, 2001). It is, therefore perhaps not surprising that women should comprise such a small proportion of the sample.

5.4 Unfortunately with so little information it is difficult to compare the characteristics, routes into secure care, risk posed and vulnerabilities of women and men. Although Hayes (2002) argues that women in secure settings have significantly different characteristics from their male counterparts, the literature review was unable to identify other studies that specifically compared the pathways to, and experiences of, men and women with learning disabilities and/or ASD in secure settings.

5.5 Nonetheless, as a sub-group (women) of a sub-group (people with learning disabilities and/or ASD in secure settings) the small numbers do make the provision of appropriate services even more problematic.

Ethnicity

5.6 All of the sample of 49 were described as 'white'. It is therefore not possible to identify the specific needs and service responses to people in secure settings from minority ethnic communities.

Age

5.7 The age range of people in The State Hospital and the psychiatric in-patient units was similar: 23 - 56 years and 24 - 56 years respectively. Within the learning disability units the age range extended from 18 - 71 years, reflecting the inclusion of both long stay and admission/assessment units within the sample.

5.8 The average age of the sample of 9 people in prison was 34 years. The range extended from 19 - 49 years. Offenders tend, on average to be younger which perhaps explains the slightly younger profile compared with those in healthcare settings.

5.9 The young people in secure accommodation were all aged under 20 years.

Nature and levels of impairment

5.10 Table 5.1 shows the nature of impairment of the sample of people for whom case recording forms were completed in each type of setting.

Table 5.1 Number of people with learning disabilities and/or ASD by type of secure unit: case recording form sample

Note
⁽¹⁾One case each of missing data

5.11 The majority of the sample had a learning disability only. In 7 cases this was combined with an autistic spectrum disorder.

5.12 Of the 32 people for whom information on level of impairment was available 15 had an assessed full scale IQ of between 60 - 70 or were described as having a "mild" or "borderline" learning disability. Several people were assessed as having "high functioning autism". A further 8 people had an assessed IQ of over 70, including one person with Asperger's syndrome who was described as having a 'normal' IQ. Within the prisons one person was assessed as having 'high functioning autism' and a full scale IQ of 85, another person was described a having a 'mild level' learning disability and a third person had an assessed full scale IQ of 67. No information was available on the level of impairment of the remaining 6 people within the prison sample.

5.13 The majority of the 9 people with an assessed IQ of under 60 were in healthcare settings, specifically the units for people with learning disabilities outwith the State Hospital. The exception was one young person in secure accommodation who was assessed as having a full scale IQ of 53. Information was not available in relation to the other 2 young people.

5.14 As noted in chapter 1, studies of people with learning disabilities in secure and forensic in-patient settings and in contact with the criminal justice system have noted that people in these environments tend to have mild or borderline learning disabilities, rather than moderate or severe levels of impairment. With the exception of the in-patient learning disability units, this pattern is largely replicated even within this small sample. It is the mild or borderline nature of the impairment which may mean some people slip through unnoticed, particularly in non-healthcare settings ( see chapter 3).

Additional mental and physical health problems and communication difficulties

5.15 Commentators have noted high rates of co-morbid mental health problems both within the general population of people with learning disabilities, including children and young people, and among offenders with intellectual disabilities (Foundation for Learning Disabilities, (2002); O'Brien (2002); Smith and O'Brien (unpublished)).

5.16 Evidence of this is also found among the sample of 49 of whom at least 24 were believed to have a mental health problem. This includes 8 of the 9 people in prison, 9 people in learning disability units, 4 in psychiatric units, and one young person in secure accommodation. Only 2 people, however, out of 11 in the State Hospital were noted as having mental health problem.

5.17 Depression was the most frequent mental health problem among the prison sample. People in the learning disability units tended to be diagnosed as having psychotic illnesses including schizophrenia. Insufficient information was available for people in the other units.

5.18 A number of people across secure settings also had chronic physical health care conditions including epilepsy, diabetes, cardiac problems and Chronic Obstructive Airways Disease.

5.19 Communication difficulties were noted in relation to 28 people out of 49, including 5 people out of the sample of 9 in prison. In the majority of cases the cause was perceived to be due to cognitive impairments or was speech related. In several cases hearing impairments were also noted.

5.20 Clearly this is a multiply impaired group of people, some of whom have mental and physical health care needs and communication difficulties. Furthermore, these individuals are not just found in healthcare settings but in secure accommodation and penal settings. How the different environments assess and respond to these multiple needs is discussed in chapters 6 and 7 below.

PAST HISTORIES

5.21 Two themes emerge from an analysis of the data on the past histories of the sample of 49. First, is the extent to which some of this background information was not available to the respondents completing the forms. Although to a degree an inevitable consequence of relying on self-completion questionnaires by people with competing demands on their time, it also perhaps reflects some of the problems of multi-agency information transmission. The accumulated histories of individuals may not follow them into, or across, different secure settings. The implications for early identification are discussed in chapter 3. Second, where this information was available it revealed the degree of prior contact people within the sample had had with health, education and social work services.

5.22 Nearly 90% of the people for whom information was available had been 'Looked After' by the local authority at some point in their lives (37 out of 42). This includes all 11 people in the State Hospital for whom case recording forms were completed, all 3 children in secure accommodation and the majority of people in learning disability, psychiatric in-patient units and in prison where this information was known. This is clearly a significant finding which raises further questions about the experiences of, and outcomes for, 'looked after' children, which extends beyond the scope of the current study.

5.23 A high proportion of the sample were known to have attended special schools - 35 people out of 41. Again the numbers were particular high among State Hospital patients and people in learning disability and psychiatric in-patient units. Among prisoners the figure is lower, 2 out of 5.

5.24 The data also indicate the level of usage of specialist health care resources in the past. Just under 80% of the sample of 46 for whom this information was available were believed to have been a patient of a hospital for people with learning disabilities at some point. This includes all the State Hospital patients in the sample, and 16 out of 20 people currently resident in learning disability units. But it also includes 6 people in prison (out of 8 for whom information was available). On the other hand, only one out of the 4 people in psychiatric in-patient units, for whom this information was known, had previously been in a learning disability unit.

5.25 In addition, 24 people in the sample had had prior contact with a Community Learning Disability Team or similar specialist team. This includes 3 people in prison.

5.26 The high level of psychiatric morbidity within the sample noted above, is given further emphasis by the finding that 26 people were known to have been patients of a psychiatric unit. Of these 6 were currently in prison, and 5 in psychiatric units.

5.27 Across the sample as a whole, 19 people had had periods as in-patients in both psychiatric and learning disability units, including 5 out of the sample of 9 people in prison. This is equivalent to the proportion with similar institutional histories in the State Hospital, where 6 out of 11 people had been in-patients of both types of unit at some point.

5.28 The past histories of in-patient care suggest that this group present significant challenges to services. For some people this is reflected in periods in different types of care: progressing along a pathway from residential care, to or from admission to local psychiatric or learning disability units or to high secure in-patient care. People in prison appear at some point to have slipped off this pathway and have ended up on a criminal justice route that has ultimately resulted in their imprisonment.

5.29 The perception held by a number of prison-based respondents was that as the large hospitals have closed so the prisons have increasingly had to accommodate people who would in the past have been admitted to, or remained in hospital. The study is not in a position to support or disprove this view. But the number of people within the prison sample with previous admissions to either hospitals for people with learning disabilities and/or psychiatric inpatient units suggests that for some people prison represents yet another institutional response to the needs they present and the risks they pose.

ROUTES TO SECURE CARE

Routes to secure care

5.30 The routes to secure care reinforce the sense of a cohort moving from one institutional environment to another. Only 6 people out of the sample of 49 were admitted direct from their current place of residence: 5 to learning disability in-patient units and one to a psychiatric unit outwith the State Hospital.

5.31 Admission to the prisons was, as would be expected, through the courts or from other prisons.

5.32 The State Hospital admitted people straight from the criminal justice system, but also from other hospitals.

5.33 None of the sample within the learning disability in-patient units came direct from prison or the courts. The majority were referred from another hospital, including 3 people moving on from the State Hospital. A number of those moving from other hospitals were being transferred because of hospital closure programmes. This appears to have affected at least 8 people out of the sample of 20.

5.34 As well as the one person admitted from their current place of residence, the psychiatric in-patient units admitted people from the State Hospital (3 people) and from the courts (one person).

5.35 Of the 3 children in secure accommodation, 2 were admitted from other residential care settings, and one from prison, via a short stay in a residential school. Two of the children had been placed following a Children's Panel hearing the third was a criminal justice disposal.

5.36 Leaving aside the people admitted to the current setting for 'administrative reasons' relating to hospital closure, those who crossover between environments comprise 3 groups. First, people moving from conditions of lesser to higher security, for example, from other hospitals to the State Hospital, or from a residential placement to secure accommodation for children, or from home to hospital, or to prison. Second, people moving in the opposite direction from higher security to lesser security, specifically from the State Hospital to other in-patient units. The third group comprise those taking a step sideways: from prison to high secure or other secure in-patient care, or to secure accommodation for children.

5.37 None of the sample crossed over from a health or social care setting to a prison setting. But, as described above, people in prison may have a history of local authority care and hospital admissions.

Current legal status

5.38 Although people may not be admitted direct from courts or prisons, data on current legal status reveals that a number of people in healthcare settings were detained under sections of the Criminal Procedures (Scotland) Act 1995. This applied to 8 of the State Hospital sample, 3 out of 20 people in units for people with learning disabilities and half of the 6 people in psychiatric units. A further 16 people were detained under the Mental Health (Scotland) Act 1984, 11 of whom were in the learning disability units.

5.39 In effect, people detained under criminal justice legislation were more likely to feature among the State Hospital and psychiatric populations, those for whom mental health legislation is applied feature more significantly among the population in the learning disability units.

5.40 Of the 3 young people in secure accommodation, one person on probation was detained under the Criminal Procedures (Scotland) Act 1995. The remaining 2 were placed under Sections 70 and 73 of the Children (Scotland) Act 1995.

Length of stay in secure settings

5.41 How long people stay in secure settings once admitted is affected by a number of factors, not all relating to changes in need. Obviously, for prisoners, the length of stay will reflect the sentence or length of period on remand. Estimating the length of stay from the point of admission to the date the case recording forms were completed reveals a range extending from one month to 29 months. Two people on remand had been in prison one month and 5 months respectively. For convicted prisoners the length of sentence varied from 16 months for one person to 10 years for 2 people.

5.42 The shortest length of stay to date among the State Hospital sample was 7 months, the longest 19.5 years.

5.43 The person with the longest period in a hospital setting was an individual in a unit for people with learning disabilities who had been a patient for over 22 years. This person was one of the sub-group of 8 people who had recently been transferred following hospital closures. Excluding the distorting affect of this group of people, the range of lengths of stay in learning disability units extended from one month to over 5 years. This reflects the inclusion of settings with different functions including assessment and continuing care. A narrower range is found in the psychiatric units: from 17 months to just under 3 years.

5.44 The 3 young people had spent between one year and 20 months in secure accommodation at the time of data collection.

5.45 The degree of movement, the variability between cases, together with incomplete data on transfer dates, particularly across and within health care settings, makes it difficult to draw firm conclusions on length of stay. The one impression that does emerge, however, is that for many people secure care is not a short stay option.

RISK TO OTHERS

5.46 Why people are in secure settings, and the lengths of time they stay, once admitted, can not be divorced from the risks they are felt to pose, both to themselves and to other people.

5.47 For people who are offenders the nature of the index offence is an indicator of the anticipated risk an individual poses towards others.

5.48 Table 5.2 summarises the offences with which people had been charged or convicted at the time of admission to the secure setting. For some people more than one offence was indicated. No information was available in relation to the children in secure accommodation.

Table 5.2 Index offence by type of secure setting: case recording form sample

5.49 What the table reveals is the seriousness of some of the offences perpetrated by this group of people, including culpable homicide, sexual offences, including rape and sexual assault, and fire raising. Further, the people committing these offences are distributed across the different secure settings for adults, including in-patient units for people with learning disabilities.

5.50 Looked at from another perspective, what the table also indicates is the numbers of people in different health care settings who have not been convicted or charged of an offence. The literature, however suggests that there is a level of under-reporting of offences by people with learning disabilities, particularly among those known to services (Lyall et al, 1995; Clare and Murphy, 1998). One health care respondent also suggested that in terms of their behaviours everyone in one secure unit was, in effect, an 'offender':

"Although they will not necessarily have been through the criminal justice system they will have perpetrated acts which would be classified as offending..if someone has a clear learning disability and IQ of 50 and is unable to control their impulsive behaviour and is assaultative then they won't be taken to court. There would be no point going to court they will already have been civilly detained and if they are taken to court they will just be assessed as unfit to plead and returned to hospital."

5.51 The comment made on one case recording form for a patient on an in-patient unit for people with learning disabilities serves to illustrate that, even if reported, the threshold for prosecution may be higher than for someone who is not learning disabled:

"No action taken for sexual offence but Procurator Fiscal said it would be taken into account if further offences."

5.52 If the index offence is an unreliable indicator of behaviour the data on the nature of the risk posed to others provides further evidence of the challenges this group of people present. Of the sample of 49, at least 31, or over 60% were believed to present a risk to others. Of these only 4 were in prison. It may be that some prison respondents interpreted risk within the context of the prison environment which, by its very nature, may minimise the opportunities to engage in certain behaviours.

5.53 The risks described on case recording forms ranged from "unpredictable violent outbursts" to "impulsive, verbal abuse, threatening and sexually inappropriate physical assault".

5.54 They are, though, not just a high risk group in terms of behaviours directed towards others, but also in terms of the harm they effect upon themselves, and the harm others in secure environments may effect upon them. In other words this is both a high risk and an 'at risk' or vulnerable group of people.

VULNERABILITIES

5.55 At least 24 of the sample were felt to be vulnerable in their current environment. This includes people in prison, in secure accommodation and on in-patient units.

5.56 Vulnerability stems from the risks people pose to themselves and the risks they are exposed to in their current environments from other people. Risks to self include self-harming or suicidal thoughts, self-neglect or non-compliance with medication. Risks from others include bullying, manipulation, abuse, or negative responses to their behaviour by other residents.

5.57 At least 17 of the sample were felt to be a risk to themselves. People with self-harming behaviour or suicidal thoughts were found across secure settings.

5.58 Several people in health care settings were at risk because of alcohol or, in one case, drug abuse.

5.59 Several prison respondents spoke anecdotally of prisoners taking someone with a learning disability "under their wing". But the data from the case recording forms suggests that they are more like to be shunned or at risk of exploitation. In environments where to stand out or appear "odd" could be a risk factor people with learning disabilities and/or ASD could be particularly vulnerable. In the prisons and secure accommodation for children, for example, there was an awareness that people with learning disabilities were at risk of being bullied or "ostracised" or of being ridiculed by others. This is underlined by the comments of one prisoner interviewed in the course of the study. When asked what was the worst thing about being there the response was: "Getting bullied by other prisoners".

5.60 People with learning disabilities were also at risk of being exploited. In several different secure environments respondents were conscious of the fact that people in the sample with learning disabilities could be used by more able residents to handle illegal substances or blamed for others' "wrong doings". In a prison context sexually inappropriate behaviour on the part of an individual with learning disabilities may also put them at risk. It was also suggested, anecdotally, that some people could be at risk of sexual abuse even within secure settings.

5.61 Chapter 7 describes in more detail how, in different contexts, people with learning disabilities and/or ASD can be outsiders or on the periphery of the environments within which they find themselves. What this means for the individuals themselves is summed up in the comments of one interviewee with a learning disability:

"The people here slag you and take liberties with you…People here are dangerous to themselves and to me…People intimidate you. People pass stuff on to you like hash or dope or take stuff off you. They take me for a ride..They take my CD and don't return it to me. It's terrible, horrible here."

SUPPORTING PEOPLE

5.62 Notwithstanding the degree of vulnerability of this group of people, only 12 were known to have been assessed under the Adults with Incapacity (Scotland) Act 2000 (AWIA). The majority of these people (10) were in-patients of the learning disability or psychiatric units. Two people in psychiatric units had a welfare guardian. Although no one in the prison sample was known to have been assessed under the AWIA, in response to a question on the unit recording forms regarding services available to meet social welfare needs one prison included "Adults with Incapacity Act". This suggests a degree of awareness of the legislation.

5.63 Ironically, however, it may be that the capacities of this group of people preclude the use of this legislation: 3 people in hospital settings who had been assessed under the AWIA were found to be "capable". Capacity, under the AWIA, is not all or nothing, but context or issue specific for example in relation to managing financial affairs, or consenting to medical treatment. Unfortunately it is not known what aspect of capacity was assessed in these cases.

5.64 One young person in secure accommodation was described as having a 'guardian', but no further information was available from the case recording forms to indicate their nature or status.

5.65 Across the sites information from the unit recording forms indicates the availability of independent advocacy services. Across the 16 prisons, 7 believed independent advocacy would be available for someone identified as having a learning disability and/or ASD. Four prisons suggested that this would not be available, the remainder did not know. In fact, for the 9 prisoners for whom more detailed information was available, none had an independent advocate. In one prison a RMHN was looking at ways of bringing in an independent advocacy agency for people with learning disabilities.

5.66 All the secure accommodation units had access to independent advocacy services. Of the 3 young people in the sample 2 had their own advocate.

5.67 All 11 people in the State Hospital sample were believed to have an advocate. This may reflect the activities of the on-site patient advocacy service.

5.68 All but 2 of the learning disability and psychiatric units outwith the State Hospital suggested that individuals would be able to obtain access to independent advocacy. One of the exceptions may have interpreted the words "in this setting" to mean on site, rather than accessible. In the second case, a unit for people with severe learning disabilities and challenging behaviour, the respondent commented that advocacy was "difficult to obtain for this group". Reflecting a gap in service provision.

5.69 In fact out of the sample of 20 people in learning disability units half had an independent advocate, as did 2 of the 6 people in psychiatric units.

DISCUSSION

5.70 In common with a number of other studies (Winter et al, 1997; Flynn and Bernard, 1999; Glaser and Deane, 1999; Alexander et al, 2002), the data reveal a multiply disadvantaged, high risk and at risk group of people.

5.71 Although information is not available on socio-economic status, past histories indicate a common pattern of previous institutionalisation and contact with statutory services.

5.72 They are also a vulnerable group of people. This vulnerability stems, on the one hand, from the combination and complexity of the behaviours they present, including self harm, physical and mental health problems and communication difficulties. On the other hand, the environments within which they find themselves may exacerbate their individual vulnerabilities. People with learning disabilities and/or ASD may be at risk of being bullied, exploited or even abused in environments where they are perceived not to 'fit in' or are seen as different.

5.73 But they are also a high risk group: some have committed, or are at risk of committing serious offences.

5.74 Given the multiple needs and risks identified across the sample the data do raise questions about the distinguishing characteristics of the populations in the different settings. The small sample size together with limited case-specific clinical information or detailed information on offending behaviours or histories means it is not possible to draw firm conclusions. The small number of women, and the absence of any people from minority ethnic communities also makes it difficult to compare experiences by gender and ethnicity. Nonetheless it is possible to identify some of the dimensions which distinguish the populations and those areas where they overlap.

5.75 The secure accommodation for children is something of a special case. The small number of young people identified makes it difficult to draw any within-group conclusions, other than to reflect on the heterogeneity of this small group in terms of their routes to secure care and their individual characteristics. What they share with each other and with the sample in secure settings for adults is the complex combination of needs, risks to self and/or others and vulnerabilities.

5.76 Focusing on secure settings for adults, the key distinguishing features include the level of IQ, the nature of co-morbid mental illness and the routes to secure settings.

5.77 In the 32 cases where this information was available, the majority of the sample had an assessed IQ of 60 and over, one-quarter of these have an IQ of over 70. The majority of people with an assessed IQ under 60 tend to be found in the units for people with learning disabilities outwith the State Hospital. This, though, is not hard and fast. Several prison respondents suggested that people with assessed IQs in the 50s have been found within the prison system.

5.78 The other distinguishing feature is the nature of co-morbid mental health problems, where identified. For people in prison this was most frequently depression. The sample of people in learning disability units with mental health problems tended to have psychotic illnesses.

5.79 The third distinguishing feature is the route to a secure environment. People referred to the State Hospital and psychiatric in-patient units came through the criminal justice system, other hospitals and occasionally direct from home. The prison sample, of necessity came through the courts or other prisons. Those in learning disability units came predominantly from other hospitals, with a few admitted from home.

5.80 Along the dimensions of index offence, or other indicators of risk to others, past histories of institutional care, combinations of mental and physical health problems and communication difficulties, there is, however, little to distinguish between the samples in the different secure settings. The prisons, the State Hospital and the in-patient units are providing care for people with histories of institutional care, with multiple impairments, who may pose significant risks to other people and/or towards themselves.

5.81 It has been suggested that responses to alleged offending can be dependent upon existing contact with services (Lyall et al, 1995; Clare and Murphy, 1998). Other research has also described how people with learning disabilities and/or ASD who engage in offending behaviour do not fit within the remit of mental health or learning disability services. As a result they may fall between service responsibilities (Winter et al 1997; Mason and Murphy 2002). The apparent overlaps in the characteristics of a sample of people in the secure settings suggest that for some individuals the routes to different secure settings may be contingent on factors such as whether they are known to services and the preparedness, or otherwise, of different services to take on responsibility for these people.

5.82 For the individuals themselves the outcomes of these contingencies may however be distinct. For example, there is evidence of greater lengths of stay for people in the State Hospital and in-patient units for people with learning disabilities. Further, as will be discussed in greater detail in chapter 7 below, the vulnerabilities of people with learning disabilities and/or ASD may be exacerbated by the environments within which they find themselves.

KEY POINTS

• The sample of 49 for whom case recording forms were completed comprised a white, predominantly male population
• The majority of the sample had a learning disability only, 4 people had an ASD, and 7 both learning disabilities and an ASD
• The majority of the sample for whom information was available had an assessed IQ of between 60 - 70. Eight people had assessed IQs of over 70, and 9 had IQs under 60. The majority of the latter were in learning disability units
• At least 24 people also had mental health problems. Among the prison population this tended to be depression. People in learning disability units tended to be diagnosed as having psychotic illnesses
• A number of people also had chronic physical health conditions. Communication difficulties were noted in relation to 28 people
• Available information on past histories indicates that the majority of people had been in local authority care at some time. A large proportion had been in-patients of learning disability or psychiatric units at some time in the past. Across the sample 19 people had had periods in both learning disability and psychiatric units
• Lengths of stay were variable in and across the secure settings, though for adults in prison these tended to be shorter on average than in healthcare settings. The young people had been in secure accommodation for between one year and 20 months
• Information on index offence and risks posed to others indicate that a number of the sample had committed quite serious offences, including sexual offences, culpable homicide and fire raising. Others may not have been convicted but were at risk of engaging in offending behaviour
• The sample was also a vulnerable group of people. A number of people were considered by staff to be at risk of self harm
• People were also felt by staff to be at potential risk from other residents within the secure environment. The possible risks identified by staff included being ostracised, bullied or exploited
• A number of people had been assessed under the Adults with Incapacity (Scotland) Act 2000. Independent Advocacy was believed to be accessible to the majority of the sample in healthcare settings and secure accommodation, although not everyone had an advocate. None of the prison sample had an independent advocate
• The key features distinguishing the profiles of the adults in the different environments include the IQ levels of individuals, the nature of co-morbid mental illness and the routes to the different types of setting. In other respects adults in different types of secure environment shared similar characteristics

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