Forensic Mental Health Nursing

Background: Sexual assault examiners provides comprehensive health care to victims of sexual assault. Communication with the victim is important to collect relevant information from the victims. Ineffective communications can cause re-victimization and hamper the medico-legal evidence collection. Main text: This article aims to orient the novice examiner and nurses to the prerequisites of medico-legal history collection, techniques of building trust, establishing rapport, ensuring privacy and confidentiality, taking consent, communicating effectively with the victims of sexual assault, and components of medico-legal history collection. Conclusions: Novice examiners and nurses need to be trained in collecting medico-legal history and evidence. The examiners who conduct the examination should be dedicated to delivering compassionate and high-quality care to individuals who have disclosed sexual assault.

As a central part of their role in working with mentally disordered offenders in secure settings, frontline workers such as mental health nurses are expected, on behalf of us all, to keep watch over their patients. They must observe and assess their movements, their progress and regress, whilst themselves being subject to scrutiny, inspection and surveillance from the wider system of care. The fact of the patients' involuntary status means that they are both dependent upon and under threat from the treatment they receive from their watchers. They too are ever vigilant and always on watch for potential threats arising from the enforced proximity with their watchers in the ward as well as from the wider judicial review systems. Disastrously the hostile dependency that is at the heart of these reciprocal roles is, from time to time, enacted in more overt violence, resulting in significant numbers of injuries, affronts and offences on both sides. There is nowhere for either group to hide to escape the scrutiny of the other. With reference to Jeremy Bentham's Panopticon (Bentham, 1995) and Michel Foucault's (1975) exploration of Bentham's ideas, our aim is to present a systems-psychodynamic exploration of the ways in which the potentially corrosive effects of these dangerous liaisons are played out between these would-be watchers and their hyper-vigilant charges. We also discuss the ever-present dynamics of shame and shaming: the illicit libidinal excitements that become invested in 'the gaze' and in the reciprocal roles of voyeur and exhibitionist as they pass between the watcher(s) and the watched in this perverse panopticon.

One peculiar characteristic of forensic work is that the capacity of the patients to act out their violent states of mind is what has resulted in their entering into treatment, rather than any more conscious motivation for treatment or recovery. This fact of their involuntary patient status means that patients’ survival is literally dependent upon, if not actively under threat from, the treatment they receive from the system of care. Disastrously this hostile dependency has, from time to time, resulted in a number of mental health workers being killed and injured by their patients and many more reports into the various ways and means in which such patients have been subjected to interpersonal and institutional mistreatment.

The focus of this chapter will be on the persistent threat to psychic survival faced both by nurses and patients in forensic settings, how these threats become manifest in the dynamic interplay between nurses (and others with the multi-disciplinary team) and those mentally disordered offender patients who are perceived to be dangerous. Our starting point is that these threats are both real and imagined and are brought about by the enforced proximity (or the avoidance of it) between nurses and patients within forensic settings.

Nursing stations that were set up to enable nurses to observe patients, have also become goldfish bowls within which nursing staff can be constantly observed and scrutinised by them. This reciprocal process of observation and scrutiny in itself creates what we have called a perverse panopticon (Scanlon and Adlam 2011a) in which all are observed and related to by all – through conscious and intentional scrutiny, as well as the more primitive forms of unconscious communication rooted in processes of projective and introjective identification.

Rather than socialising, the perverse panopticon provides a context within which pro-social forces can be corrupted and staff, as the arbiters of some of these would-be pro-social forces, can become contaminated. In their contaminated states of mind, they then present a clear and present danger to those who they watch over. As was the case with Foucault’s historical lazar-houses and the fictional citizens of Camus’ plague-stricken town, the anxiety of the perverse panopticon gives rise to a very real psycho-somatic fear of relationally transmitted dis-eases as well as the omnipresent threat that it might manifest itself as real physical violence. It is as if the very atmosphere of the ward is contaminated by a terrifying yet invisible environmental pollution which cannot easily be symbolised, nor can it be avoided or ignored –regardless of whether or not one is a wearer of the ‘white coat’.

In the forensic treatment setting each party is watching the other for any sign of the aggression, violence or seduction which might put them in harm’s way. There is a persistent threat to psychic survival faced both by the workers and the patients inhabiting these boundariless universes where the intrusiveness of looking and being looked at is everywhere. In this perverse and ‘unboundaried’ environment the very real dangerousness of the patient mirrors the ways in which they experience themselves as endangered by the boundariless and perverted advances of the would-be helper and vice versa. In these settings there is nowhere for either sub-group to hide.