DEVELOPING FORENSIC MENTAL HEALTH SERVICES PAUL E MULLEN

1. DEVELOPING FORENSIC MENTAL HEALTH SERVICES PAUL E MULLEN

2. Why Forensic Mental Health Services Should Have A High Priority Mental Health Grounds Large numbers of severely mentally ill people accumulate in prisons. General mental health services often struggle with violent and other problem behaviours (e.g. sex offending, stalking, arson) Mentally abnormal offenders are amongst the most disadvantaged of our patients but also are often among the most responsive to treatment.

3. Why Forensic Mental Health Services Should Have A High Priority • Social Grounds • Mentally ill people contribute disproportionately to violent and criminal behaviour and appropriate care can reduce the occurrence and recurrence of such offending; • The general public places a high priority on controlling behaviour in the mentally ill; • Providing high quality community based mental health care for the majority depends on effectively caring for and controlling the disruptive and violent

4. Prison population rate 2003(remand and sentenced) per 100,000 of national population • Faroe islands 21 • India 29 • France 93 • Germany ` 98 • Australia 115 • Canada 116 • England & Wales 141 • New Zealand 155 • USA 701

5. PREVALENCE OF AUSTRALIAN PRISONERS WITH A MENTAL ILLNESS • Major mental disorder 8% m. 15% f. (psychosis) • Schizophrenias 5% m. 6% f. • Personality disorders 39% m. 49% f.

6. MENTAL DISORDERS IN SERIOUS OFFENDERS in 3838 males (1993-1995) Wallace et al (1998)

7. Violent Offending in Schizophrenia(2861)

8. Schizophrenia Developmental Difficulties Active Symptoms Personality Vulnerabilities Education Failure Unemployment Social Dislocation Substance Abuse Criminal Peer Group Rejection by Services Violent Behaviours

9. Necessary Elements in a Forensic Mental Health Service I • Statewide community forensic M.H.S.* • Court liaison service.* • Court Assessment service O.P.,* prison based* and I.P. unit. • Prison based services – reception screening*, O.P. services*, inpatient units – acute* and long stay*, vulnerable prisoner units,* suicide prevention teams. Separate services for the seriously personality disordered O.P. & I.P.

10. Necessary Elements in a Forensic Mental Health Service II • High Secure I.P. Services.* • Medium Secure I.P. Services.* • Low Secure I.P. Services.* • Hostel & supervised accommodation.* • Separate Forensic Services for Intellectually Disabled * and Personality Disordered* in the community. • Separate Child & Adolescent Forensic M.H.S.*.

11. GENERAL MENTAL FORENSIC COMMUNITY REHABILITATION MEDIUM AND LOW HIGH SECURITY FACILITY SECURITY FACILITIES SERVICES SERVICES HEALTH SERVICES

12. Problem Conflict between Care & Containment Solution I • Externalise Containment – High Security Perimeter 5.2m wall with anti-grappling fronds, electronic surveillance with movement detectors within 5m of wall. • Security staff restricted to entry ports and wall. • Only clinical and support staff in the hospital itself.

13. Problem Conflict between Care & Containment Solution II • Design which minimises the wall’s visibility. • Internal hospital environment.The building design is hospital not prison based. Patients not locked in room, (except short term seclusion). Views, open space, changing vegetation, domestic standard construction. • Education and recreation blocks community standard. • Therapeutic rather than Custodial culture.

14. SECURITY CUSTODIALTHERAPEUTIC Observe (from office) Interact (in unit) Reward conformity Reward engagement and initiative Emphasise behaviour Emphasise psych adjustment Oriented to immediate goals Oriented to long term goals of institutional functioning of good social and interpersonal functioning in the community

15. SECURITY CUSTODIALTHERAPEUTIC Unified approach and Multiple Professional a approaches and perspective (authoritarian) perspectives (negotiated) Physical structure Therapeutic interventions constrain behaviour & social expectations constrain unwanted behaviour Ultimate goal control Ultimate goal effective function without antisocial and self damaging behaviours.

16. Problem Stagnation and Therapeutic Nihilism Solutions • Combining high, medium and low security in environment of rehabilitation gives patients and staff sense of progress. • Prisoner patients – acutely ill, rapid response, early discharge (4 weeks). • Staff able to move between aspects of service. • Presence of students.