August 28th, 2021

Forensic psychiatry services provide care to offenders who have been diagnosed with mental illness and rehabilitate these patients for potential re-entry into the community. They also aim to decrease risk of recidivism through individualised management plans, writes Megha Chandrashekara.

Not all offenders with mental illness will be treated in these units, and a vast proportion of this population are treated within prisons. There are different levels of security for in-patient facilities, and in medium secure units, the patients have been detained under the Mental Health Act and are deemed to hold a considerable risk of danger to the public.

My four-week elective took place at the John Howard Centre, a medium security forensic psychiatric unit based in Homerton, housing just over 200 patients. This unit has a variety of wards, each accommodating for patients at different stages of their care, and separate specialised acute wards such as the dedicated personality disorder ward and the learning disability ward. I was based on Limehouse ward, which is one of the wards focusing on rehabilitation and is a gateway to either transfer to a low secure unit or discharge. The most common mental illness seen in the centre include schizophrenia and schizoaffective disorders, as well as personality disorders which can, and often, co-exist. Dissocial personality disorder is the most common in the male population, as opposed to borderline personality disorder in the female population. Conditions co-morbid to personality disorders, such as ADHD, are also prevalent.

My role during this placement was mainly observatory as I was not permitted to undertake any clinical tasks and was always escorted around the hospital. I gained a thorough insight into the complexities of the rehabilitation process and interacted with many of the patients and staff members. I learnt that successful rehabilitation is often an act of balancing patient freedom and a satisfactory quality of life, with the potential risks to society that this may bring.

At the John Howard Centre, patients are provided care from multiple specialised staff members. Nursing care involves tasks such as regular observations and providing one-to-one support whilst providing other staff with an invaluable insight into the subtleties surrounding each patient’s behaviour and care. They are often the first to recognise signs of destabilisation of a patient.

Social workers liaise with the patient’s family, oversee victim issues, patient finances and housing. Occupational therapy provides a variety of individual and group activities, allowing patients to adhere to a structured timetable to relieve boredom and allow a sense of purpose. Patients can build on social skills and independence which are important in facilitating re-entry into the community and decreasing risk of recidivism. Doctors oversee the physical health of patients, including medication initiation and review, and they manage leave applications for patients.

The structure of the leave process involves a step-by-step relaxation of containment starting with escorted leave and moving onto unescorted and overnight leave. Once the patient has satisfied the requirements of the leaves, they are able to work towards getting discharged, however this is dependent on a variety of factors. Finally, psychological therapists are responsible for assessing patients that are acutely unwell and offer therapy to meet the patient’s specific needs. They are also able to facilitate referral to the substance misuse service.

During ward rounds, I witnessed a unique set-up in comparison to medical ward rounds where multiple members of the multi-disciplinary team were present and the patient undertook a more central role. Common themes that were brought up included offering different forms of therapy, medication changes, ward behaviour and deterioration in functioning, physical health, and discussion of the leave application. In my experience, patient concerns mostly revolved around leave applications and the timeliness of these, perhaps because these are part of the bridge to discharge and offer them an opportunity for freedom.

A key issue that staff members had to deal with on the ward is substance abuse and controlling accessibility to drugs, which is a problem often aggravated by interactions between patients and group mentality. Substance abuse can not only lead to symptom relapse, but also result in loss of leave. It was suspected that this was one of the factors behind the rapid destabilisation of one of the patients on the ward, who was moved to seclusion for a period of time. The environment of low stimuli, bare walls and lack of social contact were things that I had in mind when imagining what seclusion would be like, however it was a very different experience to being there. I could truly sense the feeling of being trapped and had to remind myself that this was a necessary and last resort to protect the safety of staff and other patients. Aside from substance abuse, other factors that commonly impact on rehabilitation include non-engagement in therapy and maladaptive coping mechanisms resulting from childhood trauma.

I attended many meetings including a risk meeting where staff members discuss past and current risks and provide feedback on how to diminish these. In the discharge meeting for one patient, I saw how there can be problems with maintaining contact with the discharged patient, therefore having a clear plan of how to ensure this is important. In the community meeting where patients attend and express any concerns that they may have, I saw the patients take on a more active role in their own management which provides many benefits for a successful therapeutic relationship. By shadowing the doctors, I saw how decisions on clinical care were made and the importance of ensuring that the patient is on the right medication at the right dose and formulation.

Throughout this placement, I most enjoyed interacting with the patients and staff and getting to know them on a personal level. This area of medicine was a lot less scientific and based more on communication and emphasised how each patient has a unique life story, neurology, personality, and behaviour so the same psychiatric illness can manifest in different ways. I also enjoyed that there was often more scope for critical analytical thinking within this field, such as when considering personality disorders. Personality disorders are highly linked to troublesome childhoods, and I had an interesting discussion with one of the doctors as to whether if the patients had had a more stable and loving childhood, they would have still developed a personality disorder or if there was some element of biological hardwiring of the brain leading to a greater predisposition to develop such a disorder.

Things that I found challenging were speaking to certain patients who were less forthcoming with giving details about their life, as it was difficult to then take an accurate history from them. It was also uncomfortable at times when being around a patient who was displaying aggressive behaviour, as this is something that I do not typically experience in a ward environment.

Overall, I am grateful to have gained valuable exposure to an area of medicine that medical students rarely get to spend time in. I have learnt even more so about the importance of teamwork and ensuring that the patient has an active role in their care, as much as possible. I have built upon my idea of what might be important when considering the capacity of a psychiatric patient, and that it cannot be automatically presumed that a patient with a mental state divergent from their baseline lacks capacity. I am grateful to Barts Guild for receipt of the elective grant, and to the staff and patients for their time and look forward to applying the lessons I have learnt to my future career.

MEGHA CHANDRASHEKARA