Psychiatric and Mental Health Nursing 3E by Elder, Evans & Nizette


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An updated new edition of the leading undergraduate mental health nursing textbook written by a renowned Australian author team.
Psychiatric and Mental Health Nursing has been the market-leading undergraduate mental health nursing textbook since it was first published in 2005.
Fully updated and packed with new research and content, this third edition cements the book’s place as an essential title for all nursing students, as well as those specialising in midwifery, community health and emergency nursing.
The book takes a holistic approach to assist nursing students understand the complex causation of mental illness. The content delves deeply into mental health diagnosis, the most effective interventions and treatment options for the mentally ill, and the consumer’s experience of mental illness.

Published in: Health & Medicine
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Psychiatric and Mental Health Nursing 3E by Elder, Evans & Nizette

  1. 1. Psychiatric and 3rd edition Mental Health Nursing 3e Psychiatric andMental HealthNursingPsychiatric and Mental Health Nursing third edition continues todeliver students and lecturers an authoritative and accessibleapproach to mental health nursing. The combined efforts of ahighly-respected and experienced editorial team and the expertiseof the contributors have resulted in a valuable and influential text,with a strong focus on evidence-based practice and recent research. Ruth Elder RN, BA(Hons), PhD Psychiatric and Ruth formerly taught and coordinated subjectsThis new edition places an important emphasis on recovery and and courses in mental health nursing for bothstrengths across all chapters dealing with mental health nursing undergraduate and postgraduate students at Mental Healthpractice, providing students with the confidence to engage a Queensland University of Technology. Her nursingrecovery-oriented, empathic and holistic approach to psychiatric practice has predominantly been in communityand mental health nursing. This edition also includes a new mental health and community health, where she worked both as a mental health nurse and as a Nursingchapter on forensic mental health nursing and addresses the community liaison nurse.integration of mental health care into primary health care. Anincreased focus on preventative mental health strategies and Katie Evans RN, BA, MLitSt, PhDcurrent and emerging interventions will help students to develop Katie has researched and taught at the University ofthe knowledge, skills and attitudes necessary to interact effectively Queensland, Queensland University of Technology,with clients and their families. Griffith University, Central Queensland University and Queensland Health. She currently designs andFeatures delivers education programs across nursing, mentall A new chapter on Forensic Mental Health Nursing health and forensic mental health on a freelance basisl A strong recovery focus throughout and is working with the Viet Nam Nursing Projectl An increased focus on preventative mental health strategies and at Queensland University of Technology, teaching, writing and directing the distance learning program. current and emerging interventionsl Case studies, critical thinking challenges and nurses’ stories Debra Nizette RN, Credentialed MHN, provide contextual reinforcement for students DipAppSc(Nursing Ed), BAppSc(Nursing),l An evidence-based framework and up-to-date research MNurStudies, FRCNA, FACMHN integrated throughout Mental health nursing requires specialist skills andl Client-focused with a clear, holistic approach knowledge, and self-awareness, which Debra believesl Free online Evolve resources available are informed by and developed through nurses’ work with consumers and carers. Debra’s current role Elder Ruth Elder as a mental health nursing advisor enables her to Evans support and promote practice embedded in holism and humanism that is consumer led and recovery Nizette Katie Evans oriented. The mental health nurses and colleagues Debra works with are passionate about education, practice and role development and leadership. Debra Nizette Collectively they generate resources for students and nurses to achieve mental health literacy or progress to specialisation, and support strategies to enhance the therapeutic potential of mental health nurses currently in practice. 3rd edition ISBN 978-0-7295-4098-8 9 780729 540988 sample proofs © Elsevier Australia
  2. 2. PSYCHIATRIC AND MENTAL HEALTH NURSING 3RD EDITION Ruth Elder RN, BA(Hons), PhD Katie Evans RN, BA, MLitSt, PhD Debra Nizette RN, Credentialled Mental Health Nurse, Endorsed Midwife, DipAppSc(Nursing Ed), BAppSc(Nursing), MNurStudies, FRCNA, FACMHN Sydney  Edinburgh  London  New York  Philadelphia  St Louis  Toronto sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 3 17/08/12 1:00 PM
  3. 3. Mosby is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 This edition © 2013 Elsevier Australia. First edition published 2005. Second edition published 2009. This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Author: Elder, Ruth. Title: Psychiatric and mental health nursing / Ruth Elder, Katie Evans and Debra Nizette. Edition: 3rd ed. ISBN: 9780729540988 (pbk.) Subjects: Psychiatric nursing—Australia—Textbooks. Psychiatric nursing—New Zealand—Textbooks. Other Authors/ Contributors: Evans, Katie. Nizette, Debra. Dewey Number: 616.890231 Publisher: Libby Houston Developmental Editor: Elizabeth Coady Editorial Coordinator: Geraldine Minto Proofread by Tim Learner Indexed by Forsyth Publishing Services Cover and internal design by Avril Makula Typeset by Midland Typesetters, Australia Printed in China by China Translation and Printing Services sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 4 17/08/12 1:00 PM
  4. 4. Contents Forewordvii PART 3 Prefaceviii Understanding mental illness211 About the editors ix 12  Intellectual disabilities213 Contributorsx Charles Harmon, Philip Petrie and Chris Taua Reviewersxii 13  isorders of childhood and adolescence234 D Mike Groome and Kristin Henderson PART 1 Preparing for psychiatric and mental 14  ental disorders of old age249 M health nursing1 Wendy Moyle  1 he effective nurse3 T 15 chizophrenic disorders264 S Debra Jackson and Louise O’Brien Murray Bardwell and Richard Taylor  2  ecovery as the context for practice14 R 16  ood disorders283 M Vicki Stanton and Barbara Tooth Peter Athanasos  3  istorical foundations35 H 17 ersonality disorders302 P Katie Evans Michelle Cleary and Jan Horsfall  4 he Australian and New Zealand T 18  nxiety disorders316 A politico-legal context54 Katie Evans Eimear Muir-Cochrane, Anthony O’Brien and 19 ating disorders339 E Timothy Wand Gail Anderson  5 rofessional and ethical issues68 P 20 ubstance-related disorders and S Anthony O’Brien, Phillip Maude and dual diagnosis362 Eimear Muir-Cochrane Janette Curtis and Peter Athanasos 21 omatoform and dissociative disorders386 S PART 2 Ruth Elder Mental health and wellness85 22 orensic mental health nursing405 F  6  ental health and illness in Australia and M Brian McKenna and Trish Martin New Zealand87 Pat Bradley and Ruth De Souza PART 4  7  Indigenous mental health in Australia and Developing skills for mental health nursing427 New Zealand109 23 ettings for mental healthcare429 S Deanne Hellsten and Hineroa Hakiaha Ruth Elder, Julie Sharrock, Phillip Maude and  8  eyond theory: understanding B Michael Olasoji mental health and illness122 24  orking with consumers W 453 Patricia Barkway Kim Usher and Kim Foster  9  ental health across the lifespan139 M 25 herapeutic interventions473 T Debra Nizette Christine Palmer 10  risis and loss161 C 26 sychopharmacology504 P Paul Morrison Kim Usher and Kim Foster 11  ssessment and diagnosis182 A Glossary522 Jan Barling Index533 v sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 5 17/08/12 1:00 PM
  5. 5. Foreword The knowledge and expertise of the mental health/ students are better prepared for the postgraduate arena psychiatric nurse are no less challenging today than of study, which then frames them with the tools for and they were in the day of Hildegard Peplau, the ‘mother of recognition as a mental health/psychiatric nurse. psychiatric nursing’. No longer is our area of expertise The uniqueness of this text is in its solid location of and specialisation granted the protection of separate our two countries. The Indigenous, ethical, social and registration across Australia and New Zealand. It is political contexts will assist students to understand our our own self-regulation through standards outlined professional knowledge and consumer care/support in by Australian and New Zealand mental health nursing the constructs of our wider society, thus acknowledging colleges and our postgraduate specialist programs that the wider factors that are socio determinants of mental are defining our parameters of practice. health and mental illness. The existence of a text for Australian and New The challenge that this text creates is twofold. First, Zealand nursing students and as a relevance point for ensuring that students are supported by lecturers/tutors mental health/psychiatric nurses is not only signifi­ who themselves have the appropriate mental health/ cant but also vital. The need for nurses to undertake psychiatric nursing specialist skills to be role models for both undergraduate and postgraduate mental health/ learning; and second, ensuring that our health/hospital psychiatric nursing programs to become mental health/ care settings provide environments conducive to this psychiatric nurses will ensure that our services and learning with our consumers. consumers have the benefit of contemporary evidenced- I hope you enjoy this text and thank the contributors based practitioners. for their time in its development. This text demonstrates active adult learning prin­ ciples in its style of engagement with its readers. As a basis Dr Frances Hughes for undergraduate education it provides the cornerstones Chief Nursing and Midwifery Officer and fundamentals of our practice. From this grounding Queensland Health vii sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 7 17/08/12 1:00 PM
  6. 6. Preface Psychiatric and Mental Health Nursing was first conceived contexts of practice and politico-legal implications in response to the clear need to provide Australian and embedded in practice. New Zealand nurses with an accessible text designed to • Part 2 aims to contextualise practice, examining actively engage undergraduate nursing students with theories about mental health and wellness across the the relevant contexts in which they were learning and lifespan and within societies and cultures, as well as working. It was also essential to provide understanding exploring crisis, loss and assessment issues. of the unique legislative, policy and cultural contexts of • Part 3 develops a better understanding of the major psychiatric and mental health nursing work in Australia mental illnesses; examines DSM-IV-TR diagnoses, and New Zealand. As the text has evolved over the past interventions and effective treatments; and 10 years, these initial goals have remained at the forefront incorporates the client’s experience of mental illness. of our writing, and this third edition continues to provide A new chapter on forensic mental health nursing has a valuable and influential text that is grounded in the been included to explain the work of mental health realities of these contexts. nurses who assist people with mental disorders who The third edition emphasises the need to adhere have become involved with the criminal justice to the principles of evidence-based practice and to use system. the most recent research from primary sources. As an • Part 4 focuses on psychopharmacology and acknowledgement of the sustained growth of the consumer therapeutic skill development for practice, and applies movement, we have incorporated a strong recovery and skills to clinical situations. strengths focus across all chapters dealing with mental This edition continues to acknowledge the import­ health nursing practice and its specialties. We promote ance of a client-focused approach and supports a holistic consumer and student-centred approaches, and focus philosophy of practice with a strengthened focus on closely on providing students with examples and guid­ recovery. This assists the beginning practitioner to under­ ance about helpful and transformative communication. stand that mental wellness is a concept that balances Wherever possible, specific suggestions about what the mental disorder, and that mental disorder is caused by a practitioner can do and say during interactions with clients complex web of circumstances. A healthy society requires have been provided. This hands-on approach is designed that mental health needs are acknowledged and services to actively engage undergraduate nursing students in developed to enhance the existing protective factors in developing the knowledge, skills and attitudes necessary our communities. to interact effectively with clients and their families. We hope that the third edition of this text continues All contributors to the text have been selected for to have wide appeal and that its practical approach their acknowledged expertise in the field of mental provides the relevant support to students and teachers, as health. Chapters written by nurses working in clinical well as practitioners in any setting who work with people and management contexts, as well as nurse academics, who have a mental health problem. In an environment communicate approaches employed by skilled nurses to where technological, professional and health service counselling, assessment, interviewing, history taking and evolution is continuous and inevitable, we continue a range of interventions. Nurses’ stories and case studies to stress the importance of a personal, empathic and drawn from the experiences of practising psychiatric holistic approach to psychiatric mental health nursing mental health nurses are included to assist students in practice. developing insights about the realities of mental health nursing. Ruth Elder The text is divided into four parts: Katie Evans • Part 1 explores broad areas such as the history of Debra Nizette mental illness and mental healthcare, the nurse, June 2012 viii sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 8 17/08/12 1:00 PM
  7. 7. About the editors Ruth Elder Debra Nizette RN, BA(Hons), PhD RN, Credentialled Mental Health Nurse, Endorsed Ruth taught and coordinated subjects and courses in Midwife, DipAppSc(Nursing Ed), BAppSc(Nursing), mental health nursing for both undergraduate and MNurStudies, FRCNA, FACMHN postgraduate  students at Queensland University of Debra is interested in the interpersonal nature of nursing Technology. Her primary interest was in the care and (mental health nursing in particular) and believes that rehabilitation of people with chronic mental disorders. students who develop self-awareness and understanding Ruth’s own nursing practice was predominately in of others are able to recognise their therapeutic potential. community mental health and community health, Debra’s aim is to support learning to assist students to where she worked as both a mental health nurse and a achieve this potential through her role in the nursing community liaison nurse. program at the Australian Catholic University in the areas of mental health nursing, psychosocial and Katie Evans professional aspects of health and nursing care and RN, BA, MLitSt, PhD therapeutic communication. Since training as a psychiatric nurse in Sydney, Katie has researched and taught at the University of Queensland, Queensland University of Technology, Griffith University, Central Queensland University and Queensland Health. At present she designs and delivers education programs on a freelance basis in a range of domestic and overseas contexts for nursing, mental health and forensic mental health students. Katie also works with the Viet Nam Nursing Project at Queensland University of Technology: teaching, writing and directing the distance learning program. Her research includes a master’s degree tracing the social evolution of women from Homer to Euripides, and a PhD investigating mental illness in the ancient Graeco-Roman literature. ix sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 9 17/08/12 1:00 PM
  8. 8. Contributors Gail Anderson Ruth Elder RN, RM, MN, Adolescent Mental Health Cert, MACN RN, BA(Hons), PhD Clinical Nurse Consultant, Adolescent Health, Westmead Hospital, NSW Katie Evans RN (Psychiatric Nurse), BA, MLitSt, PhD Peter Athanasos Director of Distance Studies, Viet Nam Nursing Project, RGN, RPN, BA, BSc(Hons) Queensland University of Technology, Brisbane, Qld Discipline of Psychiatry, Flinders University Kim Foster Murray Bardwell RN, BN, DipAppSc, MA, PhD, MRCNA, FACMHN RN, Credentialled Mental Nurse, DipAppSc, BN, MNSt Associate Professor Mental Health Nursing, (Flinders) Sydney Nursing School, The University of Sydney, NSW Mental Health Clinician (Peri Natal), St John of God Hospital, Ballarat, Vic Michael Groome (Ex MHN) BA, MSc, PhD, MAPsS Patricia Barkway Former Lecturer, School of Nursing, Australian RN, CMHN, BA, MSc(PHC), FACMHN Catholic University (Ret.); Clinical Psychologist Senior Lecturer, Mental Health Nursing, School of Nursing and Midwifery, Flinders University, Adelaide, SA Hineroa Hakiaha – Ngati Awa, Ngai Tuhoe, Jan Barling Ngati Maniapoto RN, MN, DipAppSc, BA, MRCNA, FACMHN RN, BN, PGDipN (MH), MN (Applied) Lecturer, Health and Human Sciences, Service Manager – Mental Health AoD – Te Runanga o Kirikiriroa Trust Inc Southern Cross University, NSW Pat Bradley Charles Harmon FACMHN, CMHN, MMHN, Grad Dip Health Ed, RN, DipTeach(Nursing), BHS(Nursing), MN, PhD, RPN, RGN FACMHN Adjunct Professional Associate, School of Health, HDR Lecturer, School of Nursing Midwifery, Student, Research Centre for Health and Wellbeing, Faculty of Health, University of Newcastle, NSW Charles Darwin University, NT Deanne Hellsten Michelle Cleary BNursSc, MMentalHlthNurs, Masters of Health RN, PhD (Research) Associate Professor, Alice Lee Centre for Nursing Program Manager / Nursing Director Rehabilitation Studies, Yong Loo Lin School of Medicine, Institute of Mental Health, Alcohol, Tobacco Other National University of Singapore, Singapore Drugs Services, Townsville Health Service District, Qld Janette Curtis Kristin Henderson RN, BA, PhD, DipPubHlth, FRCNA, MACMHN RN, RM, RPN, Member ACMHN, DipAppSc(Nursing Senior Fellow, University of Wollongong, NSW Ed), BNursing, GradDip Sciences Communication, Ruth De Souza Master Health Science (Deakin) Dip Nurs, GradDip Adv Nursing Practice, MA, PhD Team Leader Inpatient Consultation-Liaison, Child Senior Lecturer, School of Health Care Practice, Youth Mental Health, Royal Children’s Hospital, AUT University, Auckland, New Zealand Children’s Health Services, Qld x sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 10 17/08/12 1:00 PM
  9. 9. CONTRIBUTORS xi Jan Horsfall Anthony O’Brien PhD RN, BA, MPhil (Hons), FNZCMHN Senior Lecturer, School of Nursing, Faculty of Medical and Debra Jackson Health Sciences, University of Auckland, New Zealand RN, PhD Professor of Nursing, Faculty of Nursing, Midwifery Michael Olasoji Health, University of Technology, Sydney, NSW RN, RPN, BNurs(Hons), PGDipMHN, PhD Candidate (RMIT), MACMHN Trish Martin Clinical Nurse Educator, Alfred Health, Vic RPN, DN Director of Nursing Research, Victorian Institute of Christine Palmer Forensic Mental Health/Adjunct Associate Professor, RN, CrMHN, DipAppSc(Nursing Ed), Monash University, Vic BAppSc(Nursing), MNurs, FACMHN Mental Health Nurse in private practice Phillip Maude RN, PhD, MN(Res), BHSci, DipMHN, Cert Addictions, Philip Petrie FACMHN RN, BN, MEdStud Associate Professor, Coordinator, Graduate Diploma Executive Director, Allevia, Bankstown, NSW in Mental Health Nursing, School of Health Sciences Julie Sharrock (Nursing and Midwifery), RMIT University, Vic RN, Credentialled MHN, General Nurs Cert, Crit Brian McKenna Care Cert, Psych Nurs Cert, BEd, MHSc (Psych Nurs), RN, PhD AdvDip Gestalt Therapy, MRCNA, FACMHN, MISPN Associate Professor, Director, Centre for Mental Mental Health Nurse, Coordinator Consultation- Health Research, School of Nursing, the University Liaison Psychiatry, St Vincent’s Hospital, NSW of Auckland; Nurse Consultant, Auckland Regional Vicki Stanton Forensic Psychiatry Services, Waitemata District Health RN, RMRN, Credentialled MHN, BA(SocWel), Board, New Zealand MA(SocSc), GradDipPubHlth, GradCertMgmt, FACMHN Paul Morrison Clinical Coordinator, Aboriginal Mental Health, RN, RMN, PhD, BA, PGCE, GradDip Counselling, South Eastern Sydney Local Health District, NSW AFBPsS, CPsychol MAPS Chris Taua Professor of Nursing and Health Studies, RN, DipN, BN, PGCertHS(MH), CertAdTch, MN(Dist), Murdoch University, WA FNZCMHN Wendy Moyle Principal Lecturer, School of Nursing Human Services, RN, BN, MHSc, PhD Faculty of Health, Humanities Science, Christchurch Polytechnic Institute of Technology, New Zealand Professor of Nursing Director, Research Centre for Clinical and Community Practice Innovation, Griffith Richard Taylor Health Institute, Griffith University, Brisbane, Qld RN, RPN, BEd Senior Lecturer/Assistant Head of School, School of Eimear Muir-Cochrane Nursing, Midwifery and Paramedicine, Australian RN, Credentialled Mental Health Nurse, BSc (Hons), Catholic University, Melbourne GradDip Adult Ed, MNS, PhD, Chair of Nursing (Mental Health), School of Nursing Barbara Tooth and Midwifery, Flinders University, SA BA(Hons), PhD (Clinical Psychology) Debra Nizette Kim Usher RN, Credentialled MHN, Endorsed Midwife, RN, DipNTeach, DipHSc, BA, MNSt, PhD, FRCNA, DipAppSc(Nursing Ed), BAppSc(Nursing), FACMHN, MNurStudies, FRCNA, FACMHN Professor of Nursing and Associate Dean for Research Mental Health Nursing Advisor, Queensland Health, Qld Studies, James Cook University, Cairns, Qld Louise O’Brien Timothy Wand RN, BA, PhD MHN, RN, NP, DAS(Nurs) GradDip(MHN), Professor of Nursing (Mental Health), University of MN(Hons), PhD Newcastle, NSW, and Western NSW Local Health Nurse Practitioner, Mental Health Liaison, District Royal Prince Alfred Hospital, NSW sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 11 17/08/12 1:00 PM
  10. 10. Reviewers Maureen Barnes Robert Laing PhD, DipClinPsych, MAPS RN, BA(Hons)Psych, MCur, MACMHN Senior Clinical Psychologist, High Secure Inpatient Casual Lecturer, School of Nursing and Midwifery, Service, The Park Centre for Mental Health, QLD Murdoch University, WA; Casual Lecturer, School of Nursing and Midwifery, University of Tasmania, Tas Janette Curtis RN, PhD, DipPubHlth, BA, FRCNA, MACMHN Sue Liersch Senior Fellow, University of Wollongong, NSW RN, MN, Credentialled Mental Health Nurse, BN(Hons), PhD Candidate, Churchill Fellow Elizabeth Emmanuel Lecturer, University of Wollongong, NSW BN, MN, MHN, Midwife, PhD Andrea McCloughen Senior Lecturer, School of Nursing, Midwifery BN, MN (Mental Health), PhD, MRCNA, FACMHN, Nutrition, James Cook University, Qld MSTTI Gihane Endrawes Senior Lecturer, Mental Health Nursing, Sydney BN, PhD, MHSc (Edu), Grad C (Research), CMH, CHP, Nursing School, The University of Sydney, NSW MANZCMHN, MANTS Nani McCluskey Lecturer, University of Western Sydney, NSW RPN, PG Cert Mental Health, MA (Applied) Nursing -- Ma ori Mental Health Professional, Community Mental Susan Gallagher Health, Wairarapa, New Zealand RN, BEd Nursing, MA(Ed), MCMHN, MRCN Senior Lecturer, School of Nursing, Midwifery and Tom Meehan Paramedicine. Australian Catholic University, NSW RN, MPH, MSocSc, PhD Associate Professor, University of Queensland Linda Goddard The Park, Centre for Mental Health, Qld RPN, RNMH, BHSc (Nsg), MEd, PhD Senior Lecturer, School of Nursing, Midwifery Paul Morrison Indigenous Health, Charles Sturt University, NSW RMN, RN, PhD, BA, PGCE, GradDip Counselling, AFBPsS, CPsychol, MAPS Val Goodwin Professor of Nursing and Health Studies, RN, BN(Hons), PhD (Melb), MACMHN Murdoch University, WA Senior Lecturer, School of Nursing, Midwifery and Daniel Nicholls Paramedicine, Australian Catholic University, Ballarat, Vic RN, BA(Hons), PhD Julie Harris Clinical Chair in Mental Health Nursing, ACT RN, DipAppSc (Nursing), BNurs, MEd (TD), MRCNA Government Health Directorate University of Lecturer, Department of Nursing and Midwifery, Canberra, ACT University of Southern Queensland, Qld Alan Robins RPN, MHN, BA, GradDipPubPol, MEd(Prel), MSW Catherine Hungerford (Hum Serv M’ment), MACMHN, Accred Role Trainer, BA, BHlthSc, BCounsStuds, GradDipEd, MLitt, MN MANZPA, MIAGP (MH NursPract), PhD Assistant Professor, University of Canberra, ACT Rachel Rossiter RN, DHSc, MN(NP), MCouns, BCouns, BHlthSc Janet Kerswell Unnasch Senior Lecturer, Program Convenor, M Mental Health RN, GradDipMH, Cert IV TAA Nursing (NP), School of Nursing and Midwifery, Mental Health Nursing Consultant and Lecturer University of Newcastle, NSW xii sample proofs © Elsevier Australia*Prelims-i-x-9780729540988.indd 12 17/08/12 1:00 PM
  11. 11. Chapter 22 Forensic mental health nursing Brian McKenna and Trish Martin Key points l Mental health nurses have begun to identify the l The role of forensic mental health services has progressed knowledge, skills and attitudes that are required to work from mainly providing containment to providing treatment with forensic clients. for forensic clients. l There is an overrepresentation of people experiencing l Risk assessment, treatment and management processes mental illness in criminal justice processes. continue to develop and to be used by nurses to meet the l Forensic clients are heterogeneous groups of people whose needs of clients and to ensure safety for the community. offending behaviour may or may not be related to their l The role of mental health nurses in forensic and justice experiences of mental illness, or the mental illness may be a settings is exciting but also fraught with ethical dilemmas. result of the offending behaviour. Key terms l civil commitment l diversion l recidivism l special circumstances l court liaison nurse l fitness to plead l risk assessment and courts l criminalisation of the l forensic mental health management l structured clinical mentally ill nurse l risk factors judgement l criminal justice system l not guilty on the grounds l security l deinstitutionalisation of mental illness Learning outcomes The material in this chapter will assist you to: l demonstrate awareness of the needs and experiences of l discuss the skills, knowledge and attitudes that are central forensic clients to forensic mental health nursing l identify specific nursing interventions for forensic clients l utilise the structured clinical judgement approach to risk l describe the components of forensic mental health services assessment, treatment and management l explain common links between mental illness and l develop an understanding of nursing in criminal justice and offending behaviour forensic mental health settings. 405 sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 405 17/08/12 12:59 PM
  12. 12. 406 PART 3 • UN DERSTAN DING MEN TAL ILLN ESS Introduction perpetrators or alleged perpetrators of crime. This role should not be confused with the title ‘forensic nurse’, The context of mental healthcare is constantly changing which is prominent in countries such as the USA. Forensic and the proactive response of mental health nurses to such nursing practice is more (but not exclusively) focused on changes is reflected in the evolution of our profession. the needs of victims of crime or those bringing an issue This chapter focuses on the needs and wellbeing of people to court (including roles such as sexual assault nurse experiencing acute or chronic mental illness who have examiners). These roles are less advanced in Australia been charged with a criminal offence or are suspected of and New Zealand (Lawson 2008). committing a criminal offence (Bradley 2009). The chapter provides a description of forensic clients and overviews The development of forensic mental what is known about the relationship between mental health services illness and offending behaviour. For many reasons, people experiencing mental illness are overrepresented in the Since the 1950s, mental health services have undergone criminal justice system. Forensic mental health services major restructuring internationally in response to have developed in New Zealand and Australia to provide deinstitutionalisation. This process involved large containment, assessment, treatment and management psychiatric hospitals being closed down in favour of of forensic clients. These services have grown from the a network of mental health inpatient wards attached recognition that neither the criminal justice system nor to general hospitals and community mental health the mental health system can adequately provide services centres to meet the needs of mental health clients. for forensics client and that the two systems must work in Deinstitutionalisation in New Zealand commenced in partnership to meet the needs of clients, and at times the the 1960s and gained momentum in the 1970s and 1980s, need for community safety. with bed numbers decreasing from 350 per 100,000 The criminal justice system includes the police who population in 1970 to less than 50 per 100,000 by the arrest people alleged to have committed a crime and the year 2000 (Simpson et al 2003). Deinstitutionalisation courts responsible for making determinations of guilt in Australia has followed a similar path over the same or innocence and for imposing penalties if the person period: the number of public and private psychiatric is found guilty. Imprisonment and community-based hospital beds has fallen from 30,000 in the early 1960s to orders are possible penalties. When the person is thought 8000 in 2006, while the general population in Australia to be experiencing mental illness, there are options for has doubled (White Whiteford 2006). diversion from police custody, court or prison to mental Deinstitutionalisation is one factor that has led to health services for assessment and treatment. However, the development of forensic mental health services. Prior most mainstream mental health services do not have to deinstitutionalisation, people experiencing mental the structural security or available treatment options illness were often admitted early in the development of to contain, assess, treat and manage certain forensic their symptoms and were commonly detained for long clients and so forensic mental health services have been periods of time. Being contained within the asylum developed. may have meant that residents were protected from the Forensic mental health services are generally inde­ consequences of many of the factors that predispose pendent of the criminal justice system and are managed them to, or increase their risk of, offending. Such factors within the health sector. Components of forensic mental include lack of insight, poor understanding of early health services include services within police custody warning signs of relapse of mental illness, pro-criminal centres, prisons and courts. Secure hospitals and com­ or pro-violence thinking, substance use, poor stress munity services are also essential components. tolerance, lack of impulse control, poor problem solving Australia and New Zealand do not particularly recog­ and lack of social skills. Nurses in the asylums provided nise specialties of nursing but the term ‘forensic mental care, support and risk management that ameliorated health nurse’ is used in this chapter to identify mental health the impact of these factors and also reduced exposure nurses who practise in criminal justice or forensic settings. to circumstances that can lead to offending behaviour Similar to other health fields, there are more nurses than (such as poverty, social disadvantage and victimisation). other specialists and nurses possess the knowledge, skills Furthermore, offences might not have been reported by and attitudes that are required to provide comprehensive staff because a considerable level of disturbed and deviant care for complex forensic clients. Although this chapter behaviours were tolerated in the asylums and treated as focuses on nursing in criminal justice and forensic settings, clinical problems rather than criminal offences. When there is no doubt that nurses in mainstream services will, the asylums closed, increasing numbers of people at some time, work in partnership with clients to address experiencing mental illness who committed offences forensic mental health needs. made contact with the criminal justice system. It is this Forensic mental health nurses in Australia and social process that is referred to as ‘the criminalisation of New Zealand primarily focus on forensic clients—the the mentally ill’ (Hiday 2003). sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 406 17/08/12 12:59 PM
  13. 13. CHAPTER 22 • FORENSIC MENTAL HEALTH NURSING 407 Tragic events have also precipitated this change. In • selected high-risk offenders with a mental illness New Zealand in the 1980s, the deaths of people in asylums, referred by releasing authorities suicides in prisons and homicides in the community • prisoners with mental illness requiring specialist perpetrated by mental health clients precipitated the mental health assessment and/or treatment in transformation of services. The Mason Report (Mason et prison al 1988) placed the responsibility for the management of • people with mental illness in mainstream mental forensic clients with the health sector and recommended health services who are a significant danger to that services should occur wherever this population their carers or the community and who require the presented, within a regionalised landscape of forensic involvement of a specialist forensic mental health mental health services. The impetus for change was service (Australian Health Ministers’ Advisory similar in Australia (Mullen et al 2000). The difficulty Council 2002, pp 3–4). of treating forensic clients in prison and the decreasing Defendants appearing in court must be fit to plead. ability to securely contain them in mainstream services If mental illness prevents a person from meeting certain for extended periods have also contributed to the need for criteria (including having an understanding of the nature forensic mental health services. Forensic clients require of the charge and the trial, being able to enter a plea and specialised services that address both their mental health being able to give instructions to the legal practitioner), needs and offence-related behaviour. then that person is likely to be ordered by the court to receive treatment until the person is fit to return to Identifying forensic clients court. A small number of clients are never fit and other processes are put in place to ensure their treatment and Forensic clients have complex needs that forensic mental supervision. health nurses must thoroughly assess in order to provide Clients are found not guilty by reason of mental holistic care in partnership with the clients and their impairment by the court when it has been proved that the carers. Apart from the clinical need for treatment, many person was so unwell at the time of the offence that they clients have rehabilitative needs related to social, cultural did not understand the nature and quality of the act (the and adaptive malfunctioning and patterns of offending offence) or did not know that the act was wrong. Clients that can present as a risk to themselves or others. who are found not guilty due to mental impairment are required to undertake treatment; the duration and The legal status of forensic clients location of the treatment will depend on the severity of Forensic clients are subject to criminal justice legislation the offence and the risk status of the client. and policies that vary greatly between Australian states A prisoner experiencing mental illness will require a and territories and between countries, but the groups transfer to a secure hospital for treatment if an adequate of forensic clients described below (Australian Health level of treatment and care cannot be provided at the Ministers’ Advisory Council 2002) can generally be prison or if the prisoner is unwilling to accept treatment. found in most places. Local legislation and policies will The policy in New Zealand and Australia is that prisoners determine where the client is placed following arrest, cannot be treated involuntarily in prison, as the potential sentencing and release, and will identify the conditions, for abuse of psychiatric treatment is ever-present in the duration of treatment and the rights of the client. In prisons. Some offenders in prison who are experiencing Australia, a National Statement of Principles for Forensic mental illness can adhere to treatment and need an Mental Health was drawn up by the Forensic Expert equivalent level of treatment and care that is available in Reference Group of the National Mental Health Working the community, such as outpatient appointments with Group of the Australian Health Ministers’ Advisory a nurse. This service may be provided by prison mental Council and endorsed by the Senate Select Committee on health in-reach teams. Some prisons have mental health Mental Health. In this statement, the groups of forensic units for the short-term assessment and treatment of clients are identified as: prisoners. Some high-risk prisoners will be referred • offenders or alleged offenders referred by police, to either a forensic hospital or a community team for courts, legal practitioners or independent statutory assessment and treatment following release from prison. bodies for psychiatric assessment and/or treatment Wherever forensic mental health nurses practice, it • alleged offenders detained, or on conditional release, is their responsibility to understand the legislation that as being unfit to plead or not guilty by reason of affects their clients. Forensic clients and their carers can mental impairment be confused by the legal processes and requirements. The • offenders or alleged offenders with mental illness nurse’s knowledge of the law needs to be used proactively ordered by courts or independent statutory bodies to to assist forensic clients and their carers to understand the be detained as an inpatient in a secure forensic facility function and impact of criminal justice legislation and • prisoners with mental illness requiring secure policies and to optimise care in the context of integrating inpatient hospital treatment security, safety and therapeutic intent. The nurse is also sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 407 17/08/12 12:59 PM
  14. 14. 408 PART 3 • UN DERSTAN DING MEN TAL ILLN ESS respectively (Office of the Auditor-General 2008). The BOX 22.1 situation is similar in Australia. The imprisonment FORENSIC MENTAL HEALTH LEGISLATION AND rate for Aboriginal and Torres Strait Islanders (1892 INFORMATION WEBSITES per 100,000 adult population) at June 2010 was 14 times higher than the rate for the non-Indigenous population New Zealand (Australian Bureau of Statistics 2010). Department of Corrections: Ministry of Health New Zealand: Cognitive and social skills Ministry of Justice: www.justice.govt. nz When a person’s ability to think clearly and relate The Mason Clinic (Auckland Regional Forensic Psychiatry constructively to others is compromised by mental Services, including an e-learning package): www. illness, the likelihood of antisocial behaviour including violence and offending is enhanced (Welsh Ogloff Australia 2003; Woods et al 2004). However, the reasons for Every state and territory has different legislation. The compromised cognitive and social ability are complex and following sites may provide a good starting point: may not relate directly to mental illness. These reasons Law and justice: may relate to diminished learning opportunities in the justice context of the family, environment and culture; harsh Mental Health Review Tribunal: or inconsistent parenting; delinquent peer associations; Queensland Forensic Mental Health Branch: and acquired brain injury. A significant proportion of forensic clients have a history of traumatic childhood Victorian Institute of Forensic Mental Health, Forensicare: experiences (Schofield et al 2006) and acquired brain injury. Therefore, the development of cognitive and social skills is a rehabilitative requirement of forensic mental health services (Ch 25 describes social skills training in more detail). Limitations in cognitive and social skills required to provide information to clients and carers to can mitigate against a socially positive response to life’s ensure that they are aware of their rights. challenges (Bennett et al 2005). Websites that may assist you to gain some under­ standing of legislation related to forensic mental health Social disadvantage are listed in Box 22.1. When assessing the needs of forensic clients, forensic mental health nurses must also consider the client’s Demographic characteristics sociocultural context. The influences of membership of Research examining forensic clients generally describes a minority disadvantaged groups and low socioeconomic similar population in terms of demographic characteristics: status are especially important (Blumenthal 2000). young, male, never married, low socioeconomic status, Forensic clients are more at risk of victimisation unemployed, poor educational achievement and itinerant compared to the general population (Wolff Shi living situations prior to conviction (Ogloff et al 2004; 2009). Victimisation includes being subjected to Silver Teasedale 2004). However, the number of violence, intimidation, sexual exploitation and financial imprisoned women and female forensic clients is growing exploitation. These needs require integrated health, in both Australia and New Zealand (Office of the Auditor- justice and social care agency responses, in order for General 2008; Australian Bureau of Statistics 2010). this population to attain acceptable levels of social There is an overrepresentation of Indigenous peoples functioning and quality of life (either in prison or in the and post-colonisation immigrant populations in forensic community) and to avoid re-offending (Harty et al 2009). mental health services. Colonisation usurped the self- Violence may be the reality of high-crime neighbour­ determination of Indigenous peoples and similarly hoods where people experiencing mental illness live immigrant populations are required to adapt to the social (Monahan 2002). There is an indication that people reality of the dominant culture. Such social adjustments experiencing mental illness move into, or fail to rise out place considerable pressure on disadvantaged groups. of, low socioeconomic localities because of the impact of These pressures are reflected in a number of adverse social the social stigma attached to the illness (Sadock Sadock indicators such as poor educational achievement, high 2003). The stigma, symptoms and course of the illness may unemployment rates, high crime rates and poor health prevent people from acquiring vocational qualifications statistics. In New Zealand, Māori and Pacific Islander and securing stable employment. Surviving on benefits ethnicities are overrepresented in New Zealand prisons. can result in them living in lower socioeconomic areas, Although Māori comprise 16% of the general population where local community norms may be more supportive and Pacific Islanders 6% (Statistics New Zealand 2007), of offending and there is the possibility of increased they make up 50% and 12% of the prison population, contact with others who are offenders (Hiday 2003). sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 408 17/08/12 12:59 PM
  15. 15. CHAPTER 22 • FORENSIC MENTAL HEALTH NURSING 409 Forensic mental health nurses need to work with Substance use those forensic clients with identified sociocultural needs Substance abuse is common in psychiatric populations, to help them to develop or restore protective social offender populations and the community generally alliances with their family and community. Supporting (Mullen et al 2000). (See Ch 20 for more information social care goals and strengthening cultural identity can about substance use and abuse, and their association with prevent further offending and assist with the client’s coexisting mental disorders.) Forensic clients have high recovery. rates of substance abuse and these coexisting conditions have a link to offending and risk of violence (Hodgins Mental illness and risk to others 2002; Ogloff et al 2004). Although the majority of people The relationship between mental illness and criminal experiencing schizophrenia are not violent, they are four behaviour is complex and varies between individuals. to five times more likely to be violent when substance Nurses need to identify the unique relationship for abuse is implicated. (See Box 22.2 for the relationships each client so that they can ascertain the risk and protective factors that need to be addressed in treatment BOX 22.2 and risk management strategies. Most offenders who EXAMPLES OF RESEARCH EXAMINING THE LINKS progress from assessment to remain on the caseload BETWEEN SCHIZOPHRENIA, SUBSTANCE USE AND of forensic mental health nurses have experience of OFFENDING serious mental illness (a psychotic illness or major • Wright et al (2002) interviewed 40 community mental health depression). clients in a British suburb that was not particularly socially The 20-year study undertaken by Wallace, Mullen deprived. They found that 48% had a history of lifetime and Burgess (2004) found that the overall frequency of offending and 25% had a history of lifetime violence. Of the violent offences was significantly higher among people clients who met the criteria for coexisting substance abuse experiencing schizophrenia than among the comparison (33%), 46% had used violence, whereas 11% with psychosis community subjects (8.2% versus 1.8%). The rate of violent only had used violence. It was noted that the offences offending among people experiencing schizophrenia predated alcohol use, but occurred after illicit drug use, gradually increased over the years of the study but there and the authors concluded that substance use may be an was no difference in the rate of increase when compared indicator of general antisocial and deviant behaviour rather to the comparison subjects over the same period. Most than a cause of offending. people experiencing schizophrenia are not violent and do • In a survey of discharged medium-security clients in the UK Scott et al (2004) found that substance use was common, but not commit criminal offences, but rates of violence and that clients with personality disorders were more likely to offending are higher than for comparison community abuse substances than those without personality disorders. subjects. Clients who abused substances were more likely than non- The offences committed by clients experiencing abusing clients to be reconvicted. schizophrenia reflect a range of factors that are present • Silver and Teasedale (2004) examined what happens to the before, during and after periods of acute illness (Hodgins relationship between mental illness and violence when 2002; Wallace et al 2004). These factors are presented stressful life events and impaired social support are taken in the section on risk assessment later in the chapter. into account. Although they found strong evidence that Taylor (2004) has attributed more serious violence to stressful life events and impaired social support are key delusions leaving people fearful and frightened by those factors affecting the social distribution of violence in the general population, individuals who abuse substances have around them and with a decreased ability to control the highest rate for violence (11.16 times greater than for personal responses to these perceived threats. Monahan those who do not use substances), followed by individuals (2002) stated that if a person with a psychotic disorder with major mental illness (4.4 times greater than for those experiences voices that command violent acts, this who are not mentally ill). increases the likelihood of violence. A study by Swanson et • The findings of the study by Arseneault et al (2000) al (2006) found that positive symptoms of schizophrenia concluded that for different reasons individuals meeting (such as hallucinations, delusions and disorganised diagnostic criteria for alcohol dependence, marijuana thinking) increase the risk of serious violence, while dependence and schizophrenia-spectrum conditions negative symptoms (such as loss of energy, loss of the were more likely than control subjects to be violent. For experience of pleasure and loss of drive) lower this risk. alcohol dependence the association was the consequent These international studies have found modest increases disinhibition; for marijuana dependence the association was contact with an underground economy and using violence in criminal and violent behaviour with serious mental as a way of solving disputes; and for those experiencing illness, but also note that there is no evidence that mental schizophrenia-spectrum conditions there was a tendency to illness causes criminal behaviour; rather, several factors see the world as threatening. Schizophrenia and substance mediate mental illness and offending. These factors abuse magnified violence but a significant amount of include antisocial tendencies or peers, and alcohol or violence was perpetrated in the absence of substance use. drug abuse (Fazel Danesh 2002). sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 409 17/08/12 12:59 PM
  16. 16. 410 PART 3 • UN DERSTAN DING MEN TAL ILLN ESS between schizophrenia, substance use and offending.) with a mental health crisis nurse, who undertakes an It is not clear whether the relationship is immediate or assessment and makes recommendations to the officers. mediated, or there may be some common cause (Taylor In both Australia and New Zealand some police services 2004). However, the links between coexisting disorders, employ nurses to work in police custody centres to assist a complex array of other risk factors and the potential with mental health, physical health and addiction needs for violence remains poorly understood (Hodgins 2002; (Paulin Carswell 2010; Witham 2000). The main Taylor 2004). mental health role of these nurses is to screen for and identify mental illness and substance abuse, as soon as Forensic clients are a heterogeneous population, pre­ possible. Following assessment, nursing interventions senting with multiple, complex biopsychosocial needs. typically focus on managing substance intoxication, Many move between the criminal justice sector and the withdrawal and overdose; acute symptoms of mental mental health sector as the two systems compete to shift illness; and self-harm and suicidal behaviour. difficult individuals (Skipworth et al 2010). The task of Nurses in custody centres are also involved in training contemporary forensic mental health services lies in police on how to identify mental illness, undertake a risk smoothing the tensions of this interface and providing assessment and relate to people experiencing mental specialist assessment and treatment for the benefit of illness. Such education can provide police with greater clients. The voices of forensic clients’ experiences of understanding and an increasing ability to recognise personal tragedy, engagement with services and the mental health problems, identify options for ensuring the road to recovery are rare in the international literature; safe containment of people experiencing mental illness Chisholm (2008) provides one such a narrative. and refer them to appropriate services for assistance. Forensic mental health services The courts The courts are another potential point of diversion Police custody centres from the criminal justice system to mental health and The process of entering the criminal justice system addiction services. In the USA and Canada, this has led commences at the point of arrest. In New  Zealand to the development of ‘special circumstances courts’ such police attend to more than 9250 mental health call- as mental health courts, and drug and alcohol courts. The outs per year (New Zealand Police 2008). Most of these aim of such courts is to interrupt the cycle of offending offences are misdemeanours and typically involve public by facilitating access to treatment for those people with nuisance behaviours such as urinating in a public place mental health and addiction problems (Wiener et al and survival crimes such as shoplifting or leaving a 2010). The delivery of services and treatment progress restaurant without paying (Hiday 2003). Management are monitored through court review by the judge. of this behaviour requires arrangements between mental Such innovations are also taking place in Australia health services and the police, so that forensic clients can and New Zealand (Richardson McSherry 2010), be diverted from the criminal justice system to inpatient although the models vary. For example, while some or community mental health services (Bradley 2009). courts have established specialist mental health sittings, Decisions on diversion require consideration of public others employ court liaison nurses to advise judges, safety, the safety of the offender and the seriousness of the lawyers and the police on issues regarding the mental charge, and they can occur at any stage of the criminal health, addiction status and needs of people presenting justice process. For example, if a person experiencing to court (Turnbull Beese 2000). Court liaison nurses a psychotic mental illness is arrested for shoplifting accept referrals from the police, from lawyers who have food in order to eat, diversion to general mental health concerns about the defendant, from the judge who might services may be possible. However, if the charge is stand down proceedings for referral purposes and from a aggravated assault, then criminal justice processes would variety of other sources including the probation service, proceed and the person’s mental health needs would be mental health services, families and self-referrals. managed within the criminal justice system. In this case, Referrals usually arise from concerns about behaviour the person might be remanded to prison while the court suspected of being related to mental illness, intellectual process proceeds and their mental health needs would be disability, communication difficulties or alcohol and addressed within the prison. drug problems. In the absence of initial mental health service A police summary of facts can often be made involvement, and in cases of alleged serious offending available to the nurse before the person is interviewed such as violent offences, people experiencing a mental and assessed. The assessment involves a mental state health emergency may be transported to police holding examination (MSE) and risk assessment. In the MSE, cells. The person’s impaired mental health state may close attention is paid to behaviour, thoughts, feelings and come to the attention of police officers, who can initiate ways of relating that might be indicative of the presence a mental health response. This often involves contact of mental illness. In the risk assessment, close attention sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 410 17/08/12 12:59 PM
  17. 17. CHAPTER 22 • FORENSIC MENTAL HEALTH NURSING 411 is paid to the extent to which the presence of symptoms health services, in either an inpatient or a community of mental illness, substance use, personality disorder setting. The objective is to secure mental health service and the person’s social circumstances might impact on placement without the impediment of court processes the level of risk that the person poses to themselves or and associated incarceration (Hartford et al 2004). other people. The level of risk will influence the judge’s If the charges are serious, such as violent offending decision about where the person is to be placed and or sex offending, the judge may request a forensic whether treatment is identified as a condition. psychiatric or psychological assessment. These reports If the charges are minor, such as those cases generally provide comment on issues of fitness to involving public nuisance, the court liaison nurse may plead and whether the person was mentally impaired be required, at the request of the court, to facilitate the at the time of the offence. The report may also make person’s engagement with general or forensic mental suggestions about treatment options for the person. NURSE’S STORY: KEVIN SEATON, COURT LIAISON NURSE I have been employed in the court liaison service for 11 years. understand the different agendas in the court context, through Before becoming a court liaison nurse, I had never entered a which the court liaison nurse is required to stay impartial. The court and had no dealings with the criminal justice system. On skill is to provide clinical information that is accurate, with a my first day on the job, I helped assess a young man who had clear rationale as to why certain recommendations are made. been arrested after an unprovoked attack on his neighbours Possible responses from the judge need to be anticipated with with a knife. He believed they were aliens who had implanted alternative suggestions being pre-planned. Sound knowledge a computer chip in his brain. We had to transfer this man to a of legislation and criminal justice processes is imperative. secure forensic mental health unit for further assessment and Court liaison nurses need to be competent and confident not treatment. only in their MSE abilities, but also in the recommendations I thought to myself, what have I let myself into? I knew nothing that arise from these assessments. The MSE must also be about the court process, court protocol, how to address a judge accompanied by a thorough assessment of risk to self and or, more importantly, how to translate an MSE into a letter to others. the court that the judge would understand. As a court liaison Court liaison nurses are independent autonomous nurse I found myself caught between the police who want to practitioners, often working in relative professional isolation convict, the defence lawyers who want the charges withdrawn outside the usual comfort zone of a hospital setting. The and the judge who wants advice on the mental health and risk court setting is alien territory, working alongside non-health status of the defendant and guidance as to where they should professionals who have a unique professional language and be placed. I really struggled trying to make sense of the court etiquette, which the nurse has to learn to become effective. process, the criminal legislation and trying to do the ‘right’ No senior medical staff are readily on hand for advice and thing for the client/defendant. assistance. Peer clinical supervision is imperative. We see and I was only two weeks into the role when I found myself in hear horrific details of offending, so support and guidance court supporting a mentally ill defendant. The aim, supported from colleagues who understand the role and its demands by the lawyers and the judge, was to seek bail to the local are critical for both competent clinical practice and our own general mental health facility under mental health legislation. wellbeing. Unfortunately, there were no beds in the region. When this was The work is both challenging and rewarding. Over the years explained to the judge with the suggestion of the alternative I have had to hone my clinical skills to enable me to practise of a further remand in prison for two days to allow a bed to be at a level of autonomous practice I would not have thought secured, the judge’s retort was vehement: ‘Don’t expect me to possible 11 years ago. I have had to learn to speak and write in a look after your mental cases in prison. You find a bed.’ I was so ‘legalistic’ language rather than just ‘nurse clinical speak’. I get embarrassed being spoken to like that in a full courtroom. But I to wear nice professional clothes (no jeans and sandals in court) also felt that I should have somehow been able to ‘find the bed’ and work and talk with professionals outside the mental health this person needed, and by not doing so I had failed to provide setting. Judges acknowledge me and listen to and respect my care for this person. opinion. The stress is high, the hours of work long, but I would These are the sorts of challenges you are presented with work nowhere else. when working in the courts. Although initially they made Source: Adapted from McKenna B, Seaton K 2007 Liaison services to the courts. me uncomfortable, the challenges quickly helped me to In: Brookbanks W, Simpson A (eds) Psychiatry and the law. LexisNexis, Wellington. sample proofs © Elsevier Australiach22-405-426-9780729540988.indd 411 17/08/12 12:59 PM