Forensic Mental Health Nursing
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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... more
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.
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.
Approximately 210 patients are admitted each year to the Western Australian State Forensic Mental Health Service, and most present with psychotic illness, along with other physical and mental comorbidities. In 2010, a healthy lifestyle... more
Approximately 210 patients are admitted each year to the Western Australian State Forensic Mental Health Service, and most present with psychotic illness, along with other physical and mental comorbidities. In 2010, a healthy lifestyle programme, which included a formal exercise
programme coordinated by an exercise physiologist, was introduced at the service. A self-report questionnaire was developed to obtain feedback on the programme, and 56 patients completed the
questionnaire during the 6-month evaluation period. As well as providing patients with access to regular physical activity, the programme also supports the recovery philosophy, where patients work in partnership with forensic mental health staff. Overall, patients reported that the programme assisted them to manage their psychiatric symptoms, as well as improving their level of fitness, confidence, and self-esteem. In addition, patients received education about the importance of regular
exercise to their mental health, and the role exercise plays in preventing chronic illness and obesity. While the benefits of exercise on mental health outcomes for people with depression and anxiety are well established, this evaluation adds to the evidence that such programmes provide similar benefits to people who have a psychotic illness and are hospitalized in an acute secure setting.
programme coordinated by an exercise physiologist, was introduced at the service. A self-report questionnaire was developed to obtain feedback on the programme, and 56 patients completed the
questionnaire during the 6-month evaluation period. As well as providing patients with access to regular physical activity, the programme also supports the recovery philosophy, where patients work in partnership with forensic mental health staff. Overall, patients reported that the programme assisted them to manage their psychiatric symptoms, as well as improving their level of fitness, confidence, and self-esteem. In addition, patients received education about the importance of regular
exercise to their mental health, and the role exercise plays in preventing chronic illness and obesity. While the benefits of exercise on mental health outcomes for people with depression and anxiety are well established, this evaluation adds to the evidence that such programmes provide similar benefits to people who have a psychotic illness and are hospitalized in an acute secure setting.
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... more
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.
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... more
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.
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.
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... more
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.
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.
Au cours des vingt dernières années, plusieurs changements sociaux et politiques ont contribué à la transformation des pratiques d’intervention en psychiatrie. Ces changements sont notamment expliqués par le rapprochement continuel des... more
Au cours des vingt dernières années, plusieurs changements sociaux et politiques ont contribué à la transformation des pratiques d’intervention en psychiatrie. Ces changements sont notamment expliqués par le rapprochement continuel des espaces hospitaliers et de justice. L’objectif de cet article est de discuter de la contribution du concept d’hétérotopie pour l’étude de ce phénomène et s’appuie sur les résultats d’une recherche ethnographique réalisée dans l’un de ces espaces, la Commission d’examen. Les considérations théoriques et méthodologiques de ce projet, de même que le rôle de la Commission d’examen, seront d’abord discutées. La première partie de cet article portera sur la juxtaposition des espaces hospitaliers et de justice et ses conséquences sur les relations existantes entre les acteurs intra- et extra-juridiques. La dernière partie de cet article s’intéressera à la signification clinique de la judiciarisation et plus particulièrement des espaces de justice en santé mentale pour le travail infirmier.
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