Finding a way in forensic services

We'll start with a trigger warning - it is likely to be the worst nightmare to need institutional care. Staff are generally well-meaning, but something happens in institutions when large numbers of people are being managed that can lead to treatment that can feel impersonal, where normalising power operates a pressure to fit into institutionalised life (Goffman, 1961; Foucault, 1975).

The criteria for forensic services (mainly secure units and forensic community teams), is to be diagnosed with a major mental illness, usually psychosis, which results in risk of harm to others. In this population, Black men are in the majority, mostly of African and African Caribbean heritage. We use the term 'Black' to denote racialised and minoritised following Deleuze and Guattari (1987).

We are aware of how we get positioned through race discourses. Dawn, a White woman, works to address the challenge of clients expecting that she will not understand their lived experience. She finds that a White person recognising the impact of racism can be felt as supportive, even if imperfect allyship, as described by Vikki Reynolds. Hibaq, a Black Somali-origin woman, is passionate about working with the forensic population. She has been challenged by service users about being part of a system, which visibly incarcerates mainly Black men.

Racist discourses have the potential to position Black men as scary, threatening, aggressive, difficult, making trouble, dangerous, invulnerable, stubborn, criminal, and needing to be managed and pride can be seen as arrogance. These powerful discourses may eclipse other important areas of people's identity and experience. Freda McEwan has spoken powerfully and poetically on being seen as Black before autistic. Autism can be stereotyped as White boys with special interests, lining up toys and not making eye contact.

In forensic services, autism is slowly but surely being recognised, noticed and diagnosed. For those who may be autistic, this lens can help us reconceptualise the experience of being in forensic services. Hospitals are noisy places with bright lights, requiring multiple meetings with many professionals, which can be overstimulating and cause sensory overload for autistic people.

Conflicting and confusing expectations from different professionals can be tricky to navigate where there is at times poor appreciation of autistic needs, for example, the need for extensive preparation for change. Some may be told that they are autistic, which may be confusing after years of being told they are schizophrenic. And some may enjoy the predictability of institutional life and not want to leave, whether or not they know they are autistic.

Recognising autism within these settings can also help us understand why and how people may act and express difficult feelings. Sometimes autistic people in services may express feelings in extreme and concrete ways, for example, threats to harm, that are not actually intentions to harm but expressions of distress, upset, anger or frustration about being misunderstood. How to tell the difference?

These difficulties in expressing feelings in a way staff can hear and understand can mean some may get stuck in secure units finding it hard to understand how they might signal to staff that they are safe enough to be discharged. Sometimes, autistic people's actions may stem from confusion as to what the professional relationship is and is not.

When staff are friendly, are they a friend? When all you see and rely on are staff, are they family? These confusions can end up being labelled 'inappropriate'. When the term 'inappropriate' is not well explained, it becomes a word that is feared and not really understood, used as a way of labelling people and dismissing their emotional experience.

This is not to make light of the real risk of transgressions and sexual violence within forensic settings. However, this is likely to impact how both staff and service users act and interact. There seems to be an expectation that staff morally guide clients regarding acceptable behaviour. This can have the effect of shutting down further exploration of difficult thoughts, feelings and disclosures of having been abused themselves.

Services are set up to monitor and manage, to prevent further harm, with the medical model as the highest treatment context. Clients can feel that their treatment is unjust and controlling, with little invitation or opportunity for self-advocacy. Hibaq talks about wanting to set a therapeutic context, by reassuring and wanting clients to feel safe, but they are already seen as different and dangerous as Black men, as forensic, never mind autistic.

Clients' views can be seen as delusions, with many around them holding the idea that they can't express their feelings and that they feel pain differently. rather than appreciating their experience of the world, which may be associated with being autistic and divergent from the neurotypical experience. Clients therefore end up caught in an 'othering' double-bind, where it is hard to prove sanity and reduced risk of harm, but they risk being dismissed and disbelieved when they try.

These clients therefore end up stuck in forensic settings. Professionals are often trained to present as experts, where 'not-knowing' is not an option or asking people, who have in their lives 'lost their minds and caused harm', about their experience, can be seen as irresponsible and risky. 

However, changes and improvements are being made. Autism is being recognised more in some who have become stuck in secure units and this is helping to understand their experiences, how their interactions with others can get misunderstood and the impact this has on how the professional system responds. There is a relatively recent specialist team called FIND (Forensic, Intellectual, Neuropsychiatric and Developmental Disorders Team) advising other teams about working with autism and learning disabilities, who are beginning to raise awareness and cascade knowledge.

This brings hope to the field, although we recognise that expertise being located in a team can leave generic professionals feeling deskilled. We have both had the experience that our personal knowledge and experience of autism was not drawn upon, or valued as much as the professional expertise of a medical understanding of autism.

Change is beginning, but there is much more to do. Through our discussions at the conference and reflections since, we are left with many questions:

• How can we draw on lived experiences of being autistic in forensic journeys?
• How can the system adapt to autism? 
• How can we manage risk in an autism-friendly way? 
• How can we help clients and their families reinterpret their lived experiences in light of a later-life autism diagnosis?
• How can we further promote positive autism identities?

Hibaq Ahmed, a Social Inclusion Worker, has worked in forensic services for 16 years and is hoping to train as a Clinical Psychologist. Hibaq is part of a community of parents with autistic children.

Dawn Thibert is a family therapist, systemic supervisor, social worker and doctoral candidate in systemic practice. Dawn has family members who are autistic and has worked in forensic services for two years. Dawn is researching communication beyond words in family therapy in the forensic context. Preferred pronouns are she/her.

Their personal reflections and observations on race, autism and intersectionality in forensic services are grounded in their presentations to the 4th Systemic Approaches to Autism conference, hosted by 'Everything is Connected' CIC in July 2023. 

Key sources

Deleuze, G. & Guattari, F. (1987/2004). A Thousand Plateaus: Capitalism and Schizophrenia. Trans. Brian Massumi. London / New York: Continuum International Publishing Group. 
Foucault, M (1975). Discipline and punish. Trans: A. Sheridan, UK: Penguin Random House.
Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor Books.
McEwen, F. (2022). Autism: Psycho Terror and Not So Special: Two Poems. Murmurations: Journal of Transformative Systemic Practice. 4(2), 148-154.  
Reynolds, V. (2014). A solidarity approach: The rhizome and messy inquiry.  In Simon, G. & Chard, A. (eds) Systemic Inquiry: Innovations in reflexive practice research. Farnhill: Everything is Connected Press.