1. 1 DEVELOPING FORENSIC MENTAL HEALTH SERVICES PAUL E MULLEN

2. 2 Why Forensic Mental Health Services Should Have A High Priority 1. Mental Health Grounds a) Large numbers of severely mentally ill people accumulate in prisons. b) General mental health services often struggle with violent and other problem behaviours (e.g. sex offending, stalking, arson) c) Mentally abnormal offenders are amongst the most disadvantaged of our patients but also are often among the most responsive to treatment.

3. 3 Why Forensic Mental Health Services Should Have A High Priority 2. Social Grounds a) Mentally ill people contribute disproportionately to violent and criminal behaviour and appropriate care can reduce the occurrence and recurrence of such offending; b) The general public places a high priority on controlling behaviour in the mentally ill; c) Providing high quality community based mental health care for the majority depends on effectively caring for and controlling the disruptive and violent

4. 4 Prison population rate 2003 (remand and sentenced) p er 100,000 of national population Faroe islands 21 Faroe islands 21 India 29 India 29 France 93 France 93 Germany` 98 Germany` 98 Australia115 Australia115 Canada 116 Canada 116 England & Wales141 England & Wales141 New Zealand155 New Zealand155 USA701 USA701

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

6. 6 MENTAL DISORDERS IN SERIOUS OFFENDERS in 3838 males (1993-1995) % ODDS RATIOS Schizophrenia Personality Disorder Substance Abuse Any Offence 2.4% (3.2) 1.7% (12.7) 6.4% (7.1) Violent Offences 3.3% (4.4) 2.6% (18.7) 8.5% (9.5) Property Offences 2.1% (2.8) 1.8%(10.2) 8.4% (9.4) Homicide 7.2% (10.1) 4% (28.7) 5.2% (5.7) Wallace et al (1998)

7. 7 Violent Offending in Schizophrenia(2861) LifetimeSchiz.ControlO.R. 95% C.I. Individuals with violent offences 235 (8.2%) 235 (8.2%) 51 (1.8%) 51 (1.8%) 4.8 4.8 3.6-6.26 3.6-6.26 Total violent offences 855 (3.6) 855 (3.6) 76 (1.5) 76 (1.5) Males13% 2.9% 2.9% 5 3.6-6.9 3.6-6.9 Females1.4% 0.3% 0.3% 5.4 5.4 1.6-18.6 1.6-18.6 5 yrs after 1 st admission 4.6% 0.7% 0.7% 7.3 7.3 3.9-13.8 3.9-13.8

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

9. 9 Necessary Elements in a Forensic Mental Health Service I 1. Statewide community forensic M.H.S.* 2. Court liaison service.* 3. Court Assessment service O.P.,* prison based* and I.P. unit. 4. 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. 10 Necessary Elements in a Forensic Mental Health Service II 5. High Secure I.P. Services.* 6. Medium Secure I.P. Services.* 7. Low Secure I.P. Services.* 8. Hostel & supervised accommodation.* 9. Separate Forensic Services for Intellectually Disabled * and Personality Disordered* in the community. 10. Separate Child & Adolescent Forensic M.H.S.*.

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

12. 12 ProblemConflict 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. 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. Security staff restricted to entry ports and wall. Only clinical and support staff in the hospital itself. Only clinical and support staff in the hospital itself.

13. 13 ProblemConflict between Care & Containment Solution II Design which minimises the wall’s visibility. 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. 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. Education and recreation blocks community standard. Therapeutic rather than Custodial culture. Therapeutic rather than Custodial culture.

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

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

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