Local district and community forensic services

General hospital psychiatric units and local psychiatric hospitals often incorporate a small locked ward facility for the management of disturbed and violent behaviour for limited periods of time. This is particularly necessary where no other facilities for such patients exist in the local region. In the absence of a suitable locked room or suite, remand prisoners may be inappropriately detained in police or other remand cells where facilities are basic. In many countries where forensic psychiatry does not yet exist as a separate developed specialty, general psychiatrists will need local facilities for the investigation and assessment of patients or their on-going care. In the Northern Territories of Australia, for example, psychiatrists are not resident and only visit periodically to carry out all necessary consultations over a few days.

Increasingly in many countries psychiatry is based in the community, with a minimal use of hospital beds. Community forensic psychiatric services are a recent development providing support for patients who have moved on to the community from inpatient forensic services such as those described above. The move into the community of patients who have been incarcerated for long periods of time, or who have a serious record of offences is perhaps the most difficult and risky of the stages of the patient's progress. It requires considerable preparation and support from a skilled multidisciplinary team including a psychiatrist, psychologist, community psychiatric nurse, and social worker, preferably with a general practitioner. Some teams return patients to be supported in the local community, but there are good reasons for support and supervision to be provided by the same clinical team that has cared for the patient over years and has built up a relationship of trust.

Community teams of nurses and social workers with other staff have developed programmes designed to divert the offender from the criminal justice system towards alternative forms of management. Assessments within hours of arrest by a team consisting of a community psychiatric nurse, probation officer, and doctor can lead to a recommendation to the court to endorse a treatment plan for a suitable person which will result in outpatient care or hospital admission with the court's approval.

Psychiatric treatment in the community for offenders who do not present a continued risk to others has been available in many jurisdictions as a requirement of a probation or supervision order from a court. This requires close collaboration with a supervising probation officer or social worker and will usually be appropriate to less serious offenders. The subject must agree to accept the guidance of the psychiatrist but treatment cannot be given without his consent.

However, in the United Kingdom the possibility of introducing compulsory treatment orders or compulsory supervision orders other than in association with a probation order has not been pursued. In the United States the term used for the provision of involuntary treatment of outpatients in the community is 'outpatient commitment'. This means a court order directing a person to comply with specified treatment, not involving the continued supervision of the person in a residential setting. It is permitted in some form by statute in virtually all American states and is explicitly provided for by 26 states and the District of Columbia. In the United States there are a number of programmes for the court-mandated outpatient treatment of the criminally insane (offenders found not guilty by reason of insanity) with, for example, a well-established programme in Oregon and Maryland.

In Israel the 1991 Mental Patients Law forces a patient to continue psychiatric care after discharge from hospital, with the threat of readmission to hospital if the patient does not comply. In New South Wales under the 1990 New South Wales Mental Health Act a community treatment order or community counselling order may be made. In Victoria, Australia, community treatment orders have been available since 1986 and restricted orders for offenders since 1992. Conversely, European countries have not generally introduced orders of this kind and there are forceful ethical arguments for and against coercive outpatient management including concern about defending the civil rights of citizens against abuses of therapeutic power.

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