14 Clinical Services
Clinical Director’s <strong>Report</strong> A rapid development in forensic mental health services is occurring in most of Australia’s states and territories. Tasmania has just opened a new inpatient unit; Queensland now has a new forensic hospital in Brisbane and a unit in Townsville; New South Wales is well advanced with plans not just for a new hospital, but an expansion and reconfiguration of all of its forensic services; Western Australia is considering ambitious plans for an expanded services for mentally ill offenders and a service for seriously personality disordered recidivist offenders (modelled on the Dangerous and Severe Personality Disordered Program recently commissioned in England). The Australian Capital Territory is also giving serious consideration to developing its own forensic mental health inpatient and community service. These Australian initiatives mirror similar developments overseas, where massive expansions have occurred over the last decade in the provision primarily of secure forensic inpatient services. The role of <strong>Forensicare</strong> in service development <strong>Forensicare</strong>, both organisationally and through the efforts of a number of individual staff members, has had the privilege of contributing to the developments in forensic services in the other states and territories. The lessons learnt in Victoria over the last decade are assisting our interstate colleagues in planning their own services. There is pleasure, and no small measure of pride, in being regarded to some extent as a model and a resource for these other services. But there is also a challenge. These new Australian services have the opportunity to start from where <strong>Forensicare</strong> reached after a decade of development. Already NSW has developed an organisational structure superior in many aspects to our own and giving priority to the development of adolescent forensic mental health services, Western Australia is contemplating what can only be regarded as an adventurous initiative in the management of high risk recidivist offenders, and Queensland is seriously facing up to the challenge of service provision for the mentally disordered offenders from our indigenous communities. Other states are leaving us considerably behind in establishing coordinated programs for sex offenders, particularly child molesters, in which systematic assessment and management is provided by integrating forensic mental health and correctional resources in the common pursuit of a safer community for our children. <strong>Forensicare</strong>’s days of being able to assume pre-eminence in the provision of forensic mental health services in Australia is over. We will now have to strive to keep up with our interstate colleagues. Our staff and clinical practice We still retain in <strong>Forensicare</strong> certain advantages. Our greatest resource is our staff and the culture of care which has developed over a decade. Few other mental health services could even attempt the radical restructuring of clinical approach represented by the Consolidating and Strengthening Clinical Programs initiative. This new approach to clinical practice augments the traditional emphasis on managing the symptoms of mental illness with an equal emphasis on both the treatment of substances abuse, and the improvement of the psychological and social disabilities which together impair our patients functioning, and increase their risks of returning to antisocial and violent behaviours. The culture of care, which employs therapeutic rather than custodial approaches to behavioural control, enables our inpatient services to manage the State’s potentially most violent and disturbed group of patients, without resort to the intimidation and force implicit in the use of security guards. Research collaborations between our nursing and psychology staff have developed systematic approaches to evaluating and managing the risks of violence in the inpatient context which are already being adopted in other services around the world. Looking to the future We can be proud of the current quality of care delivered by <strong>Forensicare</strong>, but not complacent. Excellence, particularly in forensic mental health care, is always fragile, and there is an ever present risk of reversion to the custodial practices of institutional oppression which has historically defined secure forensic services. The energetic and able input from our consumer consultants is one defence against such degeneration. The quality of our clinical staff is another. Above all, we are defended from deteriorating back into the practices of yesterday by an environment characterised by openness to new ideas, research, and the self-critical monitoring and willingness to change which makes quality improvement a reality. These defences are, for all their apparent solidity, vulnerable to policy decisions over which we have little control. We live in a time when punitive responses dominate the western world’s approach to the fear of crime and criminals. Imprisonment rates continue to skyrocket, guaranteeing nothing but larger and larger cohorts of men and women destined for lives of crime. We also live in a community where fiscal restraint is bearing heavily on the less politically appealing areas of state funded health care, including mental health. We are able to glimpse current signs of more enlightened approaches from the State Government. This however, will avail us little without effective advocacy. We must also make constant efforts to make clear to the community and their representatives that what we provide at <strong>Forensicare</strong> is not just good medicine, but a real contribution to a safer community. Paul E Mullen MB BS, DSc., FRANZCP, FRC Psych. Professor of Forensic Psychiatry, Monash University Clinical Director, Victorian Institute of Forensic Mental Health 15