This article discusses the vital role of forensic mental health nurses within the counter-terrorism Prevent programme
In this article, we discuss the role of forensic mental health nurses in the Prevent counter-terrorism programme. We briefly outline the UK counter-terrorism strategy and describe the role of the mental health teams that operate alongside counter-terrorism police. Mental health nursing in this setting requires a specialist skillset, drawing on knowledge developed in inpatient and community forensic services. A case study is used to explain the activities, challenges and outcomes of those involved in this work.
Citation: Carrington T et al (2022) Prevent: the role of mental health nurses in counter-terrorism programmes. Nursing Times [online]; 118: 7.
Authors: Toni Carrington and Hayley Cushing are clinical nurse specialists, Central Counter Terrorism Vulnerability Support Hub; Sarah Sanderson is specialist forensic nurse practitioner and nurse manager, North Counter Terrorism Vulnerability Support Hub; Luc Taperell is forensic nurse specialist and team lead, South Counter Terrorism Vulnerability Support Hub.
- This article has been double-blind peer reviewed
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Terrorism – defined as the unlawful use of violence and intimidation, especially against civilians, in the pursuit of political aims (HM Government, 2018a) – not only causes great physical harm, but also has a significant impact on the safety of communities and society at large (HM Government, 2018a).
CONTEST is the UK’s counter-terrorism strategy that was first developed by the Home Office in 2003, with the aim of reducing the risk to the UK and its interests overseas from terrorism. It has four strands:
- Prevent – to stop people becoming terrorists or supporting terrorism;
- Pursue – to stop terrorist attacks;
- Protect – to strengthen the UK’s protection against a terrorist attack;
- Prepare – to mitigate the impact of a terrorist attack (HM Government, 2018a).
This article is focused on Prevent, which is about safeguarding and should be considered in the same context as support provided to people at risk of involvement with drugs, gangs or other forms of harm. Prevent is concerned with all forms of extremism and addresses vulnerabilities to radicalisation, a process that can lead some people to adopt and act on a violent extremist view, break the law and, in some cases, commit acts of terrorism (Corner and Gill, 2015). Guidance on Prevent is outlined in Box 1.
Box 1. Why should nurses refer to Prevent?
- Prevent statutory guidance is issued under section 29 of the Counter-Terrorism and Security Act 2015
- The health sector is well placed to contribute to the Prevent strategy to identify individuals who may be drawn into terrorist activity – Prevent is safeguarding
- The NHS has a statutory safeguarding duty to uphold the Prevent agenda
- Anyone can refer to Prevent – including nurses, NHS staff, education staff, social services or the general public – if they have a safeguarding concern that relates to any form of extremist vulnerability
- It is important to be aware of workplace policy in relation to Prevent and to attend the statutory Prevent training
- NHS staff should refer to their individual workplace policy in relation to making a referral to Prevent. For other services, including staff working in education, refer through the Prevent leads or designated safeguarding leads via the anti-terrorist hotline (telephone number: 0800 789 321) or the police (telephone number: 101)
Nurses and other health professionals have a responsibility to make or consider a referral to the Prevent counter-terrorism programme under the NHS England Prevent duty guidance from the Home Office (2021), which states that “healthcare professionals will meet and treat people who may be vulnerable to being drawn into terrorism”. The health sector needs to ensure that healthcare workers can identify early signs of an individual being drawn into radicalisation. Staff must be able to recognise key signs of radicalisation and be confident in referring individuals to their organisational safeguarding lead or the police, thus enabling them to receive the support and intervention they require.
Box 2 gives more details about what might trigger a referral to Prevent. On acceptance of a referral, the case is allocated to a counter-terrorism case officer, referred to as a CTCO or a Prevent officer. The Prevent referral is also sent to a vulnerability support hub (VSH) if there are indications of mental health and/or multiple and complex needs. The VSH involves a multidisciplinary team of experienced psychiatrists, psychologists, nurses and police with administrative support.
Box 2. What would trigger a Prevent referral?
We have a responsibility to make or consider a referral to Prevent under NHS England’s Prevent duty (Home Office, 2021). The National Police Chiefs’ Council (nd) suggests potential key signs as:
- Having a need to find an identity, belonging, status or excitement
- Being in a transitional phase of life
- Being susceptible to being influenced or controlled – or wanting to dominate others
- Feeling a sense of grievance, injustice or being under threat
- Having an emotional desire for political or moral change
- Having mental health-related issues
- Being secretive about social networking contacts
Other things to look out for include:
- Evidence of a change in behaviour/engagement/motivation/escalation/verbal threats
- Making comments in relation to terrorism or holding strong political views, such as those that are racist or right wing
- Signs that a person is being exploited or is vulnerable
- Monetary donations being made to concerning causes
- Change in religion and expression of beliefs (note a change in religion is not a reason to refer to Prevent but, along with other concerns outlined above, a referral could be beneficial)
- Exposure to racism/criminality/conflict
- Expressing ideological beliefs, especially if out of the ordinary for that person
- Signs/symbols/posters/flags/books in the home that may raise concern
- Recent critical events, such as trauma/loss
Our service users can be affected by what is in the news (for example, a terror attack, a school shooting, religious or political unrest and wars/riots), which may cause them to be concerned and/or increase their interest in current issues.
It is important to note that you can make a referral if you are concerned about an establishment or provider, not just a person. It is better to be on the side of caution so, if there are any concerns, a referral should be made for Prevent to review. Discuss the concern with a line manager and the team, and always discuss with the Prevent lead/coordinator or the safeguarding lead in the organisation. Ensure the evidence, discussion and decision is documented and, if at all possible, discuss with the service user if it is felt to be appropriate.
Research has shown that:
- Those at risk of radicalisation often have a range of complex mental health difficulties;
- Many people referred to Prevent have multiple and complex needs – including those relating to mental health, housing, substance misuse – and are at risk of criminal activity, including reoffending (Birmingham and Solihull Mental Health NHS Foundation Trust, 2017);
- A high proportion of individuals referred to Prevent are unknown to, or are not engaging with, mental health services;
- People with multiple and complex needs require lots of different types of support, but often have ineffective contact with – and fall though the gaps in – services (Home Office, 2021).
A rationale was developed for setting up forensic mental health teams to work with counter-terrorism police (Birmingham and Solihull Mental Health NHS Foundation Trust, 2016), which led to the creation of the VSH in the West Midlands in 2016, followed by two pilot sites in Manchester/Leeds (classed as North VSH) and London. The three hubs cover the geographical area of the whole of England and Wales.
The CTCO will also discuss the case with the local Channel Panel (Home Office, nd). Individuals referred to Prevent can consent to work with the Channel Panel, which meets once a month and takes a multidisciplinary intervention approach to support individuals who are at risk of radicalisation. The Channel Panel is arranged by the local authority and attended by a wide range of agencies including health, mental health, education and social services. There may also be involvement from intervention providers, who are specialist mentors employed by the Home Office to work with individuals in a one-to-one therapeutic relationship.
Box 3 outlines some other key facts about the Prevent programme.
Box 3. Key facts about the Prevent programme
- Between April 2017 and March 2018, there were 7,318 referrals to the Prevent programme
- Of these, 1,314 were discussed at a Channel Panel – 662 for Islamist concerns, 427 for far-right concerns, and 225 for other concerns
- More than 780 individuals have left the Channel Panel process since April 2015 with no further terrorism-related concerns
Source: Home Office (nd)
Vulnerability support hubs
The VSH works with a CTCO to try to:
- Reduce the risk of people being radicalised and vulnerable people being drawn into extremism;
- Understand and address individuals’ vulnerabilities, thereby mitigating risk;
- Identify unmet mental health needs;
- Improve health and criminal justice outcomes for individuals;
- Reduce costs through efficient partnership working, shorter durations of untreated mental illness and fewer investigations.
Each hub has an embedded multidisciplinary mental health team that works collaboratively with the police and health providers. The purpose of a VSH is to safeguard vulnerable individuals who have mental health and/or complex needs issues and are at risk from radicalisation, by supporting healthcare providers to offer care and treatment. The focus is on working in partnership to discourage stigma, help individuals to access the care they need, and work collaboratively with health providers to ensure those referred have timely access to appropriate services and treatment.
The nurses in the VSHs always adhere to the principles of Nursing and Midwifery Council (NMC) legislation and guidance as set out in the NMC’s (2018) code of conduct.
Evolving community teams
Community mental health and learning disability nurses working alongside counter-terrorism police is a new and innovative role. In general, these teams have changed significantly over the years, reflecting the varied requirements and different support packages needed. One type of service definitely does not fit all.
Historically, community mental health and learning disability nursing has involved supporting a smooth transition from hospital back to community settings, providing mental health reviews, medication management and practical signposting, as required. They also traditionally involved support to prevent unnecessary admissions to hospital by providing a similar package of care based in the home. Since the 1990s, however, the roles have become increasingly diverse and also provide mental health support in court, prison and police custody settings.
It is accepted and understood that many service users in maximum- and medium-security settings can be rehabilitated back to the community. However, to do so, a service needs to show:
- How mental health links to risk;
- Whether that risk links to harm to others;
- How risk will be mitigated.
Evidence-based risk assessments have been developed to help people leaving a highly managed setting, and this prompted the evolution of community forensic mental health nursing. Practitioners working in community forensic mental health deal with ongoing risk assessment and support (NICE, 2017). Identifying risk and early warning signs for such behaviour allows forensic nursing teams to mitigate concerns with appropriate actions, which may include medication reviews, additional support measures, engagement with additional services or readmission to hospital (Woods, 2020).
Risk assessments can be done in various settings, from secure hospitals to prisons and court or custody settings, where risk formulation and recommendations are essential. This requires an understanding of legal processes, laws, roles and responsibilities in the criminal justice system, and how mental health and complex needs interact with risk during a person’s recovery (Royal College of Psychiatrists, 2016).
The knowledge and experience staff develop in community and forensic settings allows risk assessment skills to be transferred to work in the context of the Prevent strategy. As well as being able to identify risk, staff need to know the range of options available to eliminate or mitigate the risk. Prevent is not just concerned with mental health, but also complex needs, and whether a person’s risk factors are present and relevant to the situation. If the presenting problem or concern is identified promptly, and with knowledge of behaviours that contribute to risk, suitable management and interventions can be identified.
Nursing in the VSH
It is important to note that the VSHs are staffed with mental health and learning disability nurses from different trusts. Despite varying titles, they are all band 6-8 nurses, who have significant experience in areas such as forensics, liaison and diversion, prison and learning disability. Their role is diverse, unique and involves independent working, with experience and knowledge in all aspects of mental health.
The specialist mental health practitioner’s role is an integral part of pioneering work that helps change the way vulnerabilities are identified and addressed in relation to Prevent and the wider CONTEST strategy. The role has been developed to provide an additional level of safeguarding and health input for referred individuals who may have mental health problems and/or complex needs, and who are at risk of radicalisation.
A key part of the role is risk identification and the production of multidisciplinary formulations, which are used to help inform agencies involved directly in the care of the people referred to the team, so that appropriate interventions and safeguarding measures can be put in place.
It is a nursing role that requires close working with police colleagues on a daily basis, advising on cases and liaising with professionals working with people in a variety of settings. It is not typically a face-to-face clinical role and the screening process is done using the information provided to the team by the police and any other professional working with the individual. The team also provides training on mental health to police and healthcare colleagues.
The nurse draws on past experiences and training in risk assessment and management, and a foundation in evidence-based practice, to identify areas of risk and concern quickly and effectively. The goal is to ensure the best outcome for the vulnerable individual and, where possible, divert them away from criminality and ensure they are appropriately safeguarded. As part of this process, the nurses work closely alongside NHS colleagues to help ensure appropriate mental health safeguarding; risk to others and self is a key concern when reviewing a case.
“Community mental health and learning disability nurses working alongside counter-terrorism police is a new and innovative role”
A referral was made to Prevent from a university Prevent lead in relation to a young person who had been posting extreme right-wing material on an open social-media platform that advocated violent acts. This person had been arrested a number of times over the previous few years for minor offences, and disclosed to police a belief that something was “wrong” with their mental health but declined to see mental health liaison and diversion services. Due to mental health concerns, the case was referred by the CTCO to the VSH; the CTCO and their police sergeant supervisor decided to visit the person.
During the visit, there were concerns because the young person did not make any eye contact with the officer and said they had joined an online group that made them feel accepted and they were enjoying learning about Nazi history. They made odd statements about the government spying on them and conspiring against them. There were many drawings on the wall of extreme right-wing signs and symbols, the room seemed untidy and chaotic, and the person was unkempt and distracted, giving cause for concern that they were struggling with poor mental health. They did not seem to understand the vulnerable position they were putting themselves in online and how they may be taken advantage of by people with more extreme views.
The CTCO contacted the VSH, expressing concerns about the young person’s apparent poor mental health and said they may need further support due to a vulnerability of being drawn into extremism. Both the CTCO and nurse felt action was needed to safeguard the person and the public. The nurse contacted the mental health services in the areas the person had lived in previously (Leeds, Cornwall and Herefordshire) to see if they were known to services, but they were not.
The nurse supported a referral to mental health services via the GP and the mental health trust Prevent lead was also notified. The referral was accepted and an assessment by the community mental health team suggested possible emerging psychosis. The early intervention in psychosis service provided medication, treatment and support.
The nurse from the VSH helped the early intervention service and CTCO with a risk management plan, with a trigger plan for a rereferral to Prevent if there were concerns in the future. The CTCO helped the early intervention service and the person to understand the risks and vulnerabilities in relation to being drawn into extremism. In addition, the Channel Panel offered an intervention provider to work though the young person’s extreme right-wing views and emerging ideology.
When the referred individual was mentally stable, the CTCO reassessed the counter-terrorism risk and found it had been negated due to the person’s mental health stabilising. They also worked with the university in relation to universities being targeted by extreme right-wing groups and offered to talk to students about online safety.
With the support of the early intervention service, the CTCO and university support services, the young person is now recovering well after a gap year from university and will continue with their studies.
Vulnerabilities can only be appropriately safeguarded if they are known, and mental health services may be unlikely to know information related to an individual’s involvement with other services or police. Nurses working in the VSH can add additional value by sharing concerns about vulnerable individuals to make sure they are kept safe, while adhering to legislation relating to information sharing (Box 4).
Box 4. Information governance
The HM Government’s (2018b) guide for information sharing outlines:
- Is there a legal basis to share patient information?
All information sharing for Prevent purposes must comply with the relevant legislation (Data Protection Act 2018, Human Rights Act 1998 and the common law duty of confidentiality), and meet the same rigour required for sharing information as for any other safeguarding concern
- Do I need patient consent to share their information for Prevent purposes?
The General Data Protection Regulation (GDPR), which underpins UK data protection legislation, has strengthened the need to show that consent is given freely. GDPR has also strengthened the need to have a clarity of purpose for sharing or processing data. However, the legislation does allow for safeguarding professionals, criminal justice agencies and others to: continue to use and share personal data to prevent and investigate crime; bring offenders to justice; or safeguard vulnerable individuals or people at risk, and keep communities safe from harm
If we have noted that an individual needs mental health intervention, we will make sure this is shared with the relevant service. This is a key area, given that vulnerable people often find themselves in the hands of criminal justice services. It is our unique placing that allows us to fill a gap that was missing; the development of this vital role is comparable to the established need for liaison and diversion nurses in custody.
It is important to remember that, as nurses, we are not the only people involved in an individual’s care, so we must work together with other agencies for the benefit of the patient. This keeps people safe by sharing potential risk. Busy and specialist services can find themselves working solo, but multiple services working together is the best way to effectively safeguard people. We are often told that multiagency working is the gold standard.
Although the ‘Prevent duty’ was controversial when it was introduced, it has brought awareness about vulnerability – and the risk of being drawn towards extremism – into the safeguarding arena. This has, in turn, saved many people from becoming involved in violence, and protected vulnerable people and the wider public from harm.
After six years of working as a successful pilot, the three VSH hubs are negotiating agreements to become an embedded service, as a collaborative partnership between the NHS and counter-terrorism policing.
- Mental health nurses are an important and integral part of reviewing referrals to Prevent
- Anyone can refer to Prevent and each trust has guidance and training of which all nurses should be aware
- Mental ill health and complex needs are key features of most Prevent referrals
- The aim is to safeguard people and reduce their risk to themselves and others
- The teams collaborate with the police and other agencies, adhering to information governance guidelines
Birmingham and Solihull Mental Health NHS Foundation Trust (2017) PREVENT In-Place. Intensive Psychological Liaison Assessment and Community Engagement. BSMHFT.
Birmingham and Solihull Mental Health NHS Foundation Trust (2016) Complex Mental Health, Psychological and Behavioural Difficulties and Problematic Social Backgrounds in Channel Referrals in England and Wales: Summary of Methodology. BSMHFT.
Corner E, Gill P (2015) A false dichotomy? Mental illness and lone-actor terrorism. Law and Human Behaviour; 39: 1, 23-34.
HM Government (2018a) CONTEST: The United Kingdom’s Strategy for Countering Terrorism. HM Government.
HM Government (2018b) Information Sharing: Advice for Practitioners Providing Safeguarding Services to Children, Young people, Parents and Carers. HM Government.
Home Office (nd) Counter-terrorism and Border Security Act 2019: Prevent and channel panel measures fact sheet. gov.uk (accessed 31 May 2022).
Home Office (2021) Revised Prevent duty guidance: for England and Wales. gov.uk, 1 April (accessed 7 June 2022).
National Institute for Health and Care Excellence (2017) Mental Health of Adults in Contact with the Criminal Justice System. NICE.
National Police Chiefs’ Council (nd) The warning signs. npcc.police.uk (accessed 14 June 2022).
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. NMC.
Royal College of Psychiatrists (2016) Rethinking Risk to Others in Mental Health Services. RCPsych.
Woods L (2020) What is a forensic mental health nurse? nurses.co.uk, 10 February (accessed 14 June 2022).