Forensic mental health services in Australia

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

Forensic psychiatry and mental health in Australia: an overview

This article reviews the development of forensic psychiatry and mental health services in Australia for the international reader. It covers the legacy of a series of colonial systems that have contributed to a modern health service that interacts with justice systems. The development of relevant legislation, hospitals, prison services, community, and courts services is reviewed. The training and academic development of professionals is covered. Gaps in service delivery and future directions are considered.

A brief history of forensic mental health services in Western Australia

OBJECTIVE

To scope the history of forensic mental health services in Western Australia since colonisation.

METHOD

A range of primary sources, including archives, reports, and oral histories was consulted.

RESULTS

Forensic mental health services were identified as historically poorly managed, under-resourced, and inconsistently delivered.

CONCLUSIONS

Current problems with forensic mental health services may be linked to historical factors.

Occupational Therapy in Forensic Psychiatry: A Review of the Literature and a Call for a United and International Response

A review and critique of the literature on occupational therapy in forensic mental health settings was conducted. The results indicate that the evidence base supporting occupational therapy in a forensic mental health setting is relatively weak. Much of the literature describing the role of occupational therapy in a secure setting is over 10 years old and lacks currency, and many of the research-based articles lack methodological rigour. Research has often been conducted in isolation and over a diverse range of topics, which means that important research questions have not been studied systematically.

This paper argues that to enhance the credibility and efficacy of occupational therapy in forensic practice, a coordinated international network of therapists needs to be established. Using the strength of multi-site studies, such a group can build the evidence base for occupational therapy practice in forensic settings. In addition, better links between occupational therapy services and local universities should be formalised in order to promote ongoing research that meets rigorous research standards.

Being in a Secure Forensic Psychiatric Unit: Every Day is the Same, Killing Time or Making the Most of It

Institutional environments are challenging settings in which to provide rehabilitation. This study describes the time use of a group of inpatients, the majority diagnosed with schizophrenia, in a secure forensic psychiatric unit in Australia. Time diaries, interviews and fieldnotes were collected over 5 weeks. Eight participants completed time diaries for two consecutive days, of whom five were also interviewed using the Occupational Performance History Interview II.

The participants' time use was dominated by personal care and leisure occupations. In general, the participants were dissatisfied with their time use, describing themselves as ‘bored’ or ‘killing time’. Many perceived that the environment created barriers to their participation in valued occupations, yet some also found occupations that provided solace, challenge or a connection with the outside world.

The findings indicate the importance of understanding individuals' unique occupational histories, interests and skills in order to create opportunities to engage them in relevant occupations that use personal resources, as part of forensic rehabilitation programmes, and the utility of the Occupational Performance History Interview II in this context. Further research exploring patient and staff perspectives on the challenges of occupational programming in forensic settings and the longitudinal impact of such programming on inpatients' occupational functioning, health and wellbeing is recommended.

Managing risks of violence in a youth mental health service: a service model description

AIM

There is a significant relationship between experiencing a severe mental illness, particularly psychosis, and exhibiting violent or offending behaviour. Reducing, if not preventing, the risks of violence among patients of mental health services is clinically warranted, but models to address this are limited.

METHODS

We provide a rationale for, and service description of, a pilot forensic satellite clinic embedded within an early intervention service for patients with emerging psychosis, mood disorder and/or personality disorders. The core elements of the programme and its implementation are described, and demographic, clinical and risk data are presented for the patients assessed during the clinic's pilot phase.

RESULTS

A total of 54 patients were referred, 45 of whom were subsequently assessed via primary or secondary consultation. The majority of patients were male, with psychosis (40%) or major depressive disorder (31%) as the most common diagnoses. Illicit substance use in the sample was common, as was previous aggression (81%) and prior criminal offences (51%). Most referrals related to assessing and managing violent behaviour (64%) and violent/homicidal ideation (38%). On the basis of the risk assessments, 71% of patients were rated as medium to high risk of offending.

CONCLUSION

Assessing and managing risks of violent offending among young patients are both clinically indicated for a proportion of patients and feasible via a forensic outreach model. Given the proliferation of early psychosis services worldwide, the issue of managing, and ideally preventing, patient risk of violence will almost certainly have wide application. However, a comprehensive evaluation of this model is required to ultimately determine the effectiveness of this approach for improving patient outcomes.

Patterns of mental health service contact before and after forensic mental health contact in New Zealand

OBJECTIVE

To describe patterns of mental health service contact before and after contact with a regional forensic mental health service (FMHS) to assist regional mental health service planning.

METHOD

All new referrals to Auckland Regional FMHS in 2006 were audited for contact with mental health services in the three years before and three years after their contact in 2006.

RESULTS

A total of 925 identified individuals were referred to the Auckland Regional FMHS in 2006, predominantly through the court (81%) or prison (17%). In the preceding three years, 30.2% of these service users had no mental health service contact, 41.4% had general adult mental health service (GAMHS) contact alone, 22.6% had both FMHS and GAMHS contact, and 5.8% had FMHS contact alone. In the three years after 2006, 13.4% had no further contact with either FMHS or GAMHS, 20.3% had GAMHS contact alone, 51.2% of the sample had contact with both FMHS and GAMHS, and 15% had only FMHS contact.

CONCLUSIONS

The service utilization patterns of this population support the establishment of strong links between GAMHS and FMHS in courts and prisons. Further research is needed to determine the specific models most likely to improve clinical outcomes.

A Prison Mental Health Screening Unit: a first for New South Wales

OBJECTIVE

The aims of this paper are to provide a description of a newly available service the Mental Health Screening Unit (MHSU), within the NSW prison system and to present the first 12 months in terms of the patients, its adaptations and its limitations.

METHODS

The first section of this paper provides a thorough description of the MHSU. The second looks at data collected for the period 1 July 2006 to 30 June 2007. A variety of databases were utilized as sources.

RESULTS

There were a total of 604 admissions. The most common primary diagnoses were schizophrenia-related disorders. There were relatively few adverse incidents, and 18% of the acute unit population were transferred to the Long Bay Prison Hospital.

CONCLUSION

The MHSU had a considerable throughput of patients and managed a range of severe mental illnesses. The initial objectives of the MHSU have broadly been achieved. There are several future areas of research discussed.

[Forensic psychiatric systems in the world]

OBJECTIVE

The study aims to approach forensic psychiatry within different contexts. It endeavors to show how this specific psychiatry science area is influenced by legal and cultural aspects.

METHOD

The bibliography reviewed had in view understanding the different ways of how to deal with law within the psychiatric sphere, from a cultural point of view.

RESULTS

there is a great heterogeneity, of different nature (legal, political, cultural, and religious) that enrich, but at the same time makes difficult, a debate about this issue.

CONCLUSIONS

there are two great obstacles to achieve a good knowledge about the practice of forensic psychiatry all over the world. The first one is represented by a heterogeneity that makes difficult its description in a comprehensible way. The second is the lack of knowledge of the cultural diverse realities. These difficulties should be a stimulus for newer studies of this characteristic. Only in this way it becomes possible to gradually increase the comprehension of this issue.

The need for the development and evaluation of preventive psychosocial forensic interventions in mainstream adult community mental health services

OBJECTIVE

This paper provides a selective review of forensic research with the aim of making recommendations for the development and evaluation of psychosocial interventions for the mainstream community mental health setting to address the needs of patients with a history of offending.

CONCLUSION

Mainstream community mental health services can be guided by existing findings in the design of psychosocial intervention and prevention programmes. There is growing need to develop and evaluate such interventions.

Mental disorders in Australian prisoners: a comparison with a community sample

BACKGROUND

The plight of those with mental health problems and the possible role of prisons in "warehousing" these individuals has received considerable media and political attention. Prisoners are generally excluded from community-based surveys and to date no studies have compared prisoners to the community.

OBJECTIVE

The objective was to examine whether excess psychiatric morbidity exists in prisoners compared to the general community after adjusting for demographics.

METHOD

Prison data were obtained from a consecutive sample of reception prisoners admitted into the state's correctional system in 2001 (n = 916). Community data were obtained from the 1997 Australian National Survey of Mental Health and Wellbeing (n = 8168). Mental health diagnoses were obtained using the Composite International Diagnostic Interview and a number of other screening measures. Weighting was used in calculating the 12-month prevalence estimates to control for demographic differences between the two samples. Logistic regression adjusting for age, sex and education was used to compare the prison and community samples.

RESULTS

The 12-month prevalence of any psychiatric illness in the last year was 80% in prisoners and 31% in the community. Substantially more psychiatric morbidity was detected among prisoners than in the community group after accounting for demographic differences, particularly symptoms of psychosis (OR = 11.8, 95% CI 7.5-18.7), substance use disorders (OR = 11.4, 95% CI 9.7-13.6) and personality disorders (OR = 8.6, 95% CI 7.2-10.3). Mental functioning and disability score were worse for prisoners than the community except for physical health.

CONCLUSIONS

This study found an overrepresentation of psychiatric morbidity in the prisoner population. Identifying the causes of this excess requires further investigation.

Community forensic psychiatry: restoring some sanity to forensic psychiatric rehabilitation

OBJECTIVE

To review clinical and legal paradigms of community forensic mental health care, with specific focus on New Zealand, and to develop a clinically based set of guiding principles for service development in this area.

METHOD

The general principles of rehabilitating mentally disordered offenders, and assertive community care programmes were reviewed and applied to the law and policy in a New Zealand forensic mental health setting.

RESULTS

There is a need to develop comprehensive community treatment programmes for mentally disordered offenders. The limited available research supports assertive community treatment models, with specialist forensic input. Ten clinically based principles of care provision important to forensic mental health assertive community treatment were developed.

CONCLUSION

Deinstitutionalization in forensic psychiatry lags behind the rest of psychiatry, but can only occur with well-supported systems in place to assess and manage risk in the community setting. The development of community-based forensic rehabilitation services in conjunction with general mental health is indicated.

Mental disorder in the New South Wales prisoner population

OBJECTIVES

To determine the prevalence of mental illness among prisoners in New South Wales (NSW), Australia.

METHOD

Mental illness was examined in two NSW prisoner populations: (i) new receptions to the correctional system; and (ii) sentenced prisoners. Reception prisoners were screened at four male centres and one female centre in NSW. The sentenced population was randomly selected from 28 correctional centres across the state. Reception prisoners were screened consecutively whenever possible while the sentenced group was randomly selected as part of the 2001 Inmate Health Survey. We adopted the same instrument, Composite International Diagnostic Interview - Auto (CIDI-A), for diagnosing mental illness as used in the Australian National Survey of Mental Health and Wellbeing.

RESULTS

Overall, 43% of those screened had at least one of the following diagnoses: psychosis, anxiety disorder, or affective disorder. Reception prisoners suffered from mental illness to a greater extent than sentenced prisoners (46%vs. 38%). Women had higher levels of psychiatric morbidity than men (61%vs. 39%). Nine percent (9%) of all prisoners had experienced psychotic symptoms (due to any cause) in the prior 12 months. Twenty percent (20%) of all prisoners had suffered from at least one type of mood disorder and 36% had experienced an anxiety disorder. Posttraumatic stress disorder was the most common disorder, diagnosed in 26% of receptions and 21% of sentenced prisoners.

CONCLUSIONS

These findings confirm that prisoners are a highly mentally disordered group compared with the general community. Given the high prevalence of mental illness identified by this study, it is essential that prison mental health services be adequately resourced to address the demand and, at minimum, ensure that mental health does not deteriorate during incarceration.

Risk assessment and management: a community forensic mental health practice model

In Victoria, the Crimes (Mental Impairment and Unfitness to be Tried) Act (1997) reformed legal practice in relation to the detention, management and release of persons found by a court to be not guilty on the grounds of insanity or unfit to be tried. This Act provides a legal structure for such 'forensic patients' to move from secure inpatient facilities into the community. This new legislative landscape has generated challenges for all stakeholders and has provided the impetus for the development of a risk assessment and management model. The key components of the model are the risk profile, assessment and management plan. The discussion comprises theory, legislation, practice implications and limitations of the model. Practice implications concern the provision of objective tools, which identify risk and document strategic interventions to support clinical management. Some of the practice limitations include the model's applicability to risk assessment and management and its dependence on a mercurial multi-service interface in after-hours crisis situations. In addition to this, the paper articulates human limitations implicit in the therapeutic relationship that necessarily underpins the model. The paper concludes with an exploration of the importance of evaluative processes as well as the need for formal support and education for clinicians.