Forensic Mental Health

Reducing and eliminating the use of restrictive practices, such as seclusion and restraint, is a national priority for Australia’s mental health services. Whilst legislation, organization and practice changes have all contributed to a reduction in these practices, forensic mental health services continue to report high rates. This paper details the findings of research that examined the experiences of nurses working in the inpatient forensic mental health setting.
The research aimed to (i) document the experiences of nurses working in the forensic mental health setting, (ii) articulate their perceived unique skill set to manage challenging patient behaviours, and (iii) determine how their experiences and skill set can inform practice changes to reduce the use of restrictive practices. Thirty-two nurses were recruited from one Australian forensic mental health service. Data were collected using semi-structured interviews and analysed using inductive content analysis. Four categories were identified that influenced practice experiences: (i) working in a challenging but interesting environment, (ii) specialty expertize, (iii) exposure to aggression and resilience as a protective factor, and (iv) the importance of effective teamwork and leadership. Forensic mental health care is complex, highly specialized, and often delivered in an unpredictable environment. Whilst high rates of restrictive practices may be linked
to the unique characteristics of forensic patients, training, teamwork, and leadership are critical factors influencing their use in this setting. Nurses working in this area need to be educated and supported to work confidently and safely with this high-risk patient cohort.

Purpose Individuals with diagnoses of autism spectrum disorder (ASD) within criminal justice settings are a highly heterogeneous group. Although studies have examined differences between those with and without ASD in such settings, there has been no examination of differences within the ASD group. The paper aims to discuss these issues. Design/methodology/approach Drawing on the findings of a service evaluation project, this paper introduces a typology of ASD within forensic mental health and intellectual disability settings. Findings The eight subtypes that are described draw on clinical variables including psychopathy, psychosis and intensity/frequency of problem behaviours that co-occur with the ASD. The initial assessment of inter-rater reliability on the current version of the typology revealed excellent agreement, multirater Kfree =0.90. Practical implications The proposed typology could improve understanding of the relationship between ASD and forensic risk, identify the most...

According to Cunningham (1992), leadership is a term worthy of global concern, especially considering the growing internationalization of industry, of which the health and social care sector is a part. Many researches and a substantial body of knowledge exist on leadership, the result, some argue, of an inherent frustration with many theories. The attributes of an outstanding leader, the relationship between personality dimensions and leadership, and the impact of leadership on group behavior and success are just a few of the topics covered.
Hitt (1993) compared attempting to “piece together” a systematic theory of leadership from the various threads running through the extensive literature to “trying to find one's way out of a forest without a map.” Nonetheless, as Sarros and Woodman point out (1993), although the factors that influence leadership effectiveness are not well understood, multiple studies have shown that leadership can influence organizational efficiency.
The impact of key management, leadership, and motivation theories on success and the overall goals of health and social care service providers will be evaluated in this study. It will also look at how important internal organizational processes like performance management are in performance management

Providing occupational therapy services in secure settings can be challenging due to a number of factors including, but not restricted to, the limitations of the physical environment. Maintaining an occupation focus in such environments can also be difficult, especially if there are competing institutional philosophies. In this article, we describe a project undertaken by a group of occupational therapists in NSW, Australia which focuses on centralising occupation in the programmes they provide in a number of units within state funded Justice and Forensic Mental Health Services. The project utilises a practice- based enquiry approach through which the practitioners engage in a reflective analysis of their everyday practices and the artefacts produced in practice. Collectively, the group of practitioners together with an academic have formed a community of practice scholars who both critique and support each other’s enquiry processes and actions aimed at transforming practice. Whilst the project is only in its early stages at the time of writing, it is hoped that the findings will inform other occupational therapists hoping to ‘reclaim occupation’ in their practice setting.
Keywords: Forensic mental health, Occupation-focussed practice, Practice transformation, Practice-based enquiry, Community of practice

Handwriting, like all other behavior, is regulated by the brain. This is typically an unconscious mechanism that is closely related to brain impulses. Any mental disorder can impair the forearm's kinetic motions, as can be seen in the subject's handwriting. It's crucial to focus on how a subject write rather than what a subject write if you want to understand health and mental issues. The aim of this analysis study is to learn about the changes that occur in an individual's handwriting characteristics during psychological problems, or when the subject is in a troubled state of mind. Calligraphy The study and analysis of handwriting, especially in relation to human psychology, is known as graphology. It has been discovered that features related to motion, time, and pressure are very useful and could be used to diagnose health and mental disorders using a manual or digital handwriting analysis approach.

History suggests that departures from accepted design practice can contribute to positive change in the delivery of mental healthcare; the daily experience of hospitalised patients; and public perceptions of mental illness. The question of how architecture can support the therapeutic journey of patients remains a critical one. The availability of evidence-based design literature to guide architects cannot keep pace with growing global demand for new forensic mental hospital facilities. This article reports a global survey of current design practice to speculate on the potential of three new hospitals to positively improve the patient experience. A desktop survey was conducted of 31 mental hospitals (24 forensic, 7 non-forensic) constructed, or scheduled for completion, between 2006 and 2022. This was supplemented by advisory panel sessions with clinical/facilities staff, alongside architectural knowledge obtained through workshops with architects from the United Kingdom and the United States, and the inclusion of Australian architects on the research team. Data analysis draws on knowledge from architectural practice, architectural history and environmental psychology, arguing that there is a responsibility to integrate knowledge from across these disciplines in respect of such a pressing and important problem.

Background
Creative arts interventions have clear benefits for recovery within forensic settings, supporting the development of personal meaning, introspection, emotional expression, self-esteem and social relationships (Clements, 2004; Gussak, 2007; 2017; Koch et al., 2015). The Graffiti Art and Wellbeing Project was an expressive arts intervention based in North London Forensic Service, and facilitated by the artist Ben Wakeling.  The project ran for twelve weeks, starting in a room on the ward and moving to an outdoor ‘therapy wall’ half way through the intervention. Here patients worked on a collaborative graffiti art work, which was documented with photographs, and then painted over each week. This evaluation aimed to understand the impacts of the Graffiti Art and Wellbeing Project on the individual patients, the staff and the unit as a whole.
Methods
A qualitative process evaluation was carried out, combining participant observation, documentation, interviews with staff (n=3) and a staff survey (n=14). The data were combined and analysed using Thematic Analysis (Braun & Clarke, 2006).
Findings
The response to the Graffiti Art and Wellbeing Project was overwhelmingly positive. It was seen by staff as an innovative intervention which offered multiple benefits to the patients taking part, and had a positive impact on the wider environment of the ward.
For patients who participated in the project, key benefits included being a way for participants to build a visual language within a trusting environment, to express emotions and facilitate self-reflection. The fact that the sessions built up slowly across several weeks meant that patients were supported to find ways to express and transform difficult emotions and experiences, in a way which felt familiar and culturally appropriate.
For staff, the project provided a chance to see beyond illness and offending, instead appreciating the creative side of patients. The project also offered an opportunity for positive risk taking, and changed the overall feel and look of the environment of the unit.
Recommendations
1. Graffiti Art and Wellbeing Project should be recommissioned
This evaluation overwhelmingly supports the effectiveness of the Graffiti Art and Wellbeing Project. We have found that the project was a successful intervention, There were multiple benefits for both patients and staff, and which stretched beyond those who directly took part in the project. We recommend that this project should be recommissioned, repeated and expanded.
2. Preserve the core elements of trust, imagination, and expression
Working from imagination, and using art as a modality to build and sustain trusting relationships emerged as key elements of the success of the project. The process of building up art engagement slowly was key to the success found in this evaluation - starting with ‘expressive roaming’ through visual expression, before graduating to working with graffiti. We recommend that any extension of the project keeps these values at the core of the project, recognising the key role of relationality in the work of the Graffiti Art and Wellbeing Project. The project needs to be facilitated from a place of respect, adapting to the needs of each individual, based on “deep and respectful observation” (Fals Borda, 2001: 33).
3. Longer time periods working with patients
The project was successful in building trust and developing self-reflection, enabling emotional expression for patients. Longer term work would enable patients to further explore and hone these skills and aspects of themselves, which are so crucial for enabling recovery and supporting desistance. We recommend repeated work in the same spaces on the wards, as well as longer term work with individual patients.
4. Permanent art studio space
A key element of the success of the project is the process of ‘expressive roaming’ through which patients are supported to develop their own visual language in the early part of the project. This is key to the early process of developing trusting relationships and emotional expression. A permanent or semi-permanent art space in the unit would provide a richer environment for this process and we would recommend finding a space to house a studio.
5. Training facilitators
We would recommend the expansion of the Graffiti Art and Wellbeing project to other services, as well as repeated work within North London Forensic Service. We recommend that Ben Wakeling be supported to train further facilitators in his approach. This training should focus on communicating the art-led ‘mode of engagement’ (Liebert et al, 2018) at the heart of the Graffiti Art and Wellbeing project – trust, imagination, and expression.
6. Opportunities for creativity and ownership
Key benefits from the project were found in the opportunities provided for patients to explore their creativity, and create a feeling of ownership over the space of the unit. These extended beyond the core sessions, for instance patients using their own sketchbooks, and photographs of the graffiti wall being exhibited on the ward. Staff could consider ways to embed some of these elements into the design and use of the space of the wards, enabling patients to see more of themselves in the environment in which they live. For example, staff could consider creating a dynamic wall in the ward where patients could choose art or images for the ward which change relatively regularly. We recommend that secure services prioritise providing more opportunities for patients to be supported in imaginative, creative activity in forms which are culturally relevant and close to their lives, such as found in this project.
 

Medium secure forensic psychiatric units are unique environments within the broader “post asylum” landscape of mental health services. Length of stay is much greater and restrictions on behavior, including sexual behavior, are legally and institutionally legitimated, due to concerns regarding risk. As a result, sexuality is rarely explored with service users and no official policies on sexual conduct and sexual safety have yet been developed, despite sexuality being linked to positive recovery outcomes.
The aim of this study was to explore with service users how they experience and more specifically “feel” their sexuality during their time in secure care and in the community. A further aim was to understand how sexuality connected with their thoughts and feelings on recovery and relationships, and their perceived impact on mental health. We report on the findings from 29 service users participating in a qualitative-visual study, using drawing as a visual technique to provide an opportunity for expression of feeling.
In this paper, the analytical focus is on how institutional practices can induce a “liminal hot-spot”, wherein an impasse between past crisis and future recovery is reached, taking theoretical direction from Stenner’s work on liminality and Fuch’s work on vitality. Specifically, we examine how service users experience liminality and the practices that emerge from such a state of living that can serve to objectify and suspend feelings of vitality. Finally, we discuss the implications of these findings for a recovery model and the development of policies on sexuality, sexual safety and relationality, within secure forensic settings.

People with mental health issues are vastly overrepresented in the Australian prison system. This paper discusses the master planning and design of Ravenhall Correctional Centre in Victoria, Australia to increase outcomes for male prisoners living with physical, mental health disability and other conditions. Major innovations in the design of Ravenhall Correctional Centre have included a forensic mental health unit on site, and the master planning of the prison into separate communities with a variety of housing types to provide prisoners opportunities to experience various levels of self-care and greater autonomy. The prison was designed to increase feelings of wellness, to provide program and training spaces to service various groups, and to allow prisoners to experience greater levels of individual control. The project is discussed through an architectural lens to allow readers to understand the complexities of master planning and designing a major people-oriented, multi-faceted prison with a forensic mental health unit within the perimeter. The paper notes that large scale prisons may be designed in a more therapeutic manner where accommodation, facilities and programs can provide prisoners opportunities to connect with external environments, engage in meaningful activities and retain a level of autonomy and individual control. The integration of the forensic mental health unit means that greater numbers of prisoners are able to access in and outpatient services. The paper concludes that since the prison was commissioned in 2017, the prisoner cohort has changed, resulting in a deviation from the intended purpose of focusing on innovative programs for sentenced prisoners. This may have diminished the capacity for prisoners to effectively engage in the programs for which the prison was designed.

Shaun Gallagher has actively looked into the possibility that psychopathologies involving “thought insertion” might supply a counterexample to the Cartesian principle according to which one can always recognize one’s own thoughts as one’s own. Animated by a general distrust of a priori demonstrations, Gallagher is convinced that pitting clinical cases against philosophical arguments is a worthwhile endeavor. There is no doubt that, if true, a falsification of the immunity to error through misidentification would entail drastic revisions in how we conceive the boundary between self and other. However, I argue that (1) the idea of unearthing an exception to the Cartesian thesis is, on further reflection, not a realistic prospect and that (2) this casts doubt on the attempt to conjoin first-person phenomenology and third-person cognitive science in the service of philosophical debates.

The scope of forensic psychiatry as a field is defined by the application of psychiatry to questions of  justice. Its mission is to study and evaluate the relationships between mental illness and criminalityand violence. In the narrow sense of the term, it refers to the clinical evaluation of the mental stateof defendants or victims in the context of criminal trials or civil lawsuits (e.g. private insurancecompanies). In the wider sense, the term refers to questions of care and evaluation within prisons,special hospitals or ordinary contexts – although the meaning varies according to country.

Multidisciplinary teams (MDTs) are conventionally recommended in mental health
care literature as an important way to offer holistic treatment provision to patients. This
study aims to explore multidisciplinary teamwork in contemporary mental health
settings, particularly what aids and hinders the process of multidisciplinary teamworking,
and the social work contribution in such teams. In order to attain an in-depth
exploration of these phenomena, a single case study design was employed. Within this
design, data were generated through semi-structured interviews and structured
observation of a mental health MDT in Ireland. These data were analysed using
interpretative phenomenological analysis. The research highlights how the concept of
mental illness is contested within this MDT, with the medical model dominant within
an environment of fluid working arrangements. Professional role blurring and
stereotyping were found to impact the division of labour on this team, with role
negotiation found to be an integral part of retaining a professional’s practice identity.
This research raises concerns for social work’s capacity to function within mental
health MDTs in Ireland, and highlights ways in which social work educators might
respond in order to empower Irish social workers to meet the challenges of mental
health multidisciplinary teamworking.