Management in forensic psychiatry

The approach to managing patients in forensic psychiatry in most respects is no different from the management of people diagnosed with mental illness in other areas of the mental health services/!1,.12ยป However, managing patients in forensic psychiatry does differ in some important respects as follows.

1. Forensic mental health practice occurs in an environment in which compulsion and even coercion play a far greater role than in general psychiatric services where voluntary treatment is the ideal, and increasingly the norm.

2. Management and treatment are often pursued in an institutional framework, such as that of the prison or forensic hospital, which is often less than optimal for therapeutic activities, and on occasion frankly inimical to such purposes.

3. There is a dual mandate for forensic mental health professionals because the context of forensic practice often places them in the position of containing and controlling, at the same time as treating and caring for, the patient. The patients not surprisingly tend to regard their period of compulsory hospital admission as a sentence (for those transferred from prison they can literally be serving a sentence).

4. As a manifestation of this dual mandate, outcomes tends to be measured in terms of social goals, such as the prevention of recidivism, as well as health goals, such as reduced symptoms and improved function.

5. The patients of forensic mental health professionals are subjected, on occasion, to forms of legal coercion which, even if consequent on the application of mental health legislation, are in practice operated as a form of preventive detention. Notions of future dangerousness or even retributive justice may administratively take precedence over the patient's mental health status. The resulting extended periods of compulsory treatment give ample opportunity to plan and implement rehabilitative efforts (a luxury rarely vouchsafed to general psychiatric services). Conversely, the extended incarceration, particularly when clearly determined by non-clinical imperatives, can breed hopelessness and resentment.

6. he forensic mental health professional will often play a role in those court and tribunal processes which initially mandated the treatment and which may eventually sanction not only an end of compulsory treatment but also an end of confinement.

7. The personality difficulties and behavioural anomalies of patients in forensic mental health services are often central irrespective of the diagnosis. This places an emphasis on treatment approaches which attempt to modify overt behaviours and remedy or ameliorate personality disorders. Behavioural treatments, particularly cognitive-behavioural approaches as well as the more traditional psychotherapeutic modes of treatment are as a result often central to managing forensic patients. (12,!3.)

These differences should not, however, be allowed to obscure the essential sameness in the aims and practices of mental health professionals in the forensic fields to those of their colleagues in other areas of psychiatry. The similarities between forensic psychiatry and general psychiatry in the area of therapeutics far outweigh any differences imposed by institutional and administrative context. However, it is on those minor differences that this chapter will often focus.

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