Forensic mental health
10-year mental health plan technical paper
Contents
Background ................................................................................................................................................................. 1
Intervening earlier ....................................................................................................................................................... 2
Challenges and opportunities ................................................................................................................................... 3
Policy and program options ...................................................................................................................................... 4
Questions for consultation ........................................................................................................................................ 4
Background
research as key elements that contribute to whether or
not a person is likely to re-offend.1
Each year 20 per cent of the general population will
experience a mental illness. In contrast, almost half (48
per cent) of the detainees brought into police custody
had previous contact with the public mental health
system. At the time of arrest, 17 per cent of people
arrested were being treated by a public mental health
service. By comparison, 1.1 per cent of the general
population receives public mental health services. At
the time of assessment, 38 per cent of newly remanded
prisoners report having previously been told by a
mental health professional that they have a mental
illness. Further, some 30 per cent of those who have
had contact with mental health services have records of
arrests or convictions for criminal offences.
The transition from prison to community for prisoners
with mental illness is even more complicated, as the
fact of mental illness is itself a barrier to achieving the
conditions conducive to refraining from offending.
Unsurprisingly, offenders with serious mental health
issues are likely to re-offend sooner and with more
frequency than those without.
The high level of mental health need amongst
offenders and the high degree of contact with public
mental health services suggests that public mental
health services need capacity and capability to work
effectively with the volume and complex needs of
people with mental illness who have offended or are at
risk of offending.
In general, exiting prisoners face multiple barriers to
reintegrating into the community following a custodial
sentence. The ability to achieve stable accommodation,
legitimate income, employment, manage good health
(including alcohol and other drug use) are all key
concerns consistently identified by prisoners and
The Department of Health & Human Services and the
Department of Justice & Regulation have responsibility
for forensic mental health services in Victoria. The
Department of Health & Human Services funds public
mental health services and a specialist forensic mental
health service - the Victorian Institute of Forensic
Mental Health (Forensicare). Forensicare delivers
inpatient and community forensic mental health
services across Victoria. The Department of Justice &
Regulation also funds Forensicare to provide
secondary mental health services in prisons. Other
providers undertake primary mental health and alcohol
and other drugs services within prisons, administered
by Justice Health.
Forensic mental health is a specialist area within the
mental health system which meets the needs of people
with mental illness who have offended or are at risk of
1
Evidence across Australia, New Zealand, America, Canada and the
United Kingdom consistently affirms this. Refer to Chapter 2 of
Department. of Justice 2005, Bridging the gap a release transition
support program for Victorian prisoners, State Government of
Victoria, Melbourne.
offending. Forensicare provides clinical assessment,
treatment and management of people with severe
mental illness and offending behaviours.
Forensicare operates Victoria’s only secure forensic
mental health hospital, Thomas Embling Hospital, as
well as a statewide Community Forensic Mental Health
Service (the community service). Forensicare also
provides mental health services in Victorian prisons
and some courts.
Thomas Embling Hospital is a 116-bed secure forensic
mental health hospital, situated in Fairfield purpose
designed and built to provide advanced clinical
treatment and programs. Most patients are from the
criminal justice system.
There are three patient types in Thomas Embling
Hospital:
• forensic patients found not guilty or unfit to be tried
under the Crimes (Mental Impairment and Unfitness
to be Tried) Act 1997 (forensic patients)
• security patients (prisoners) who require compulsory
mental health treatment under the Mental Health Act
2014
• civil patients of area mental health services unable
to be managed in the community and who require
compulsory treatment under the Mental Health Act
2014 in a high-secure environment.
All patients at Thomas Embling Hospital have access to
a range of therapeutic programs designed to provide
purposeful, meaningful and individually and socially
valued activities. The therapeutic programs focus on
assisting patients to reconstruct a positive, adaptive
sense of themselves.
The programs provided by the Community Forensic
Mental Health Service are primarily for people who
have a serious mental illness and have offended, or are
at high risk of offending. Specialist assessment and
treatment is also provided for people who present with
a range of serious problem behaviours.
Services are only provided on the basis of a referral
and subsequent assessment. Most clients are referred
from area mental health services, Corrections Victoria,
courts, Adult Parole Board, Thomas Embling Hospital,
Acute Assessment Unit at Melbourne Assessment
Prison, other government agencies and private
practitioners.
Services are provided through five programs:
• Mental Health Program – this includes Primary,
Secondary and Tertiary Consultations, Community
Forensic mental health
Integration Program and Non-custodial Supervision
Order Consultation and Liaison Program
• Problem Behaviour Program
• Court Services – including Pre-Sentence Court
Reports and Mental Health Court Liaison Service
• Forensic Clinical Specialist Program
• Youth Justice Mental Health Program.
The Centre for Forensic Behavioural Science operates
as the research arm of Forensicare, under the auspices
of Forensicare and Swinburne University of
Technology. The centre brings together academics,
clinicians, researchers and students from a variety of
disciplines.
Intervening earlier
Both early identification, and systematic intervention
early in the illness pathway, can help prevent people
from relapsing into severe mental illness and being
subsequently propelled to crisis, often needing
intervention involving police, ambulance services,
hospitalisation and the justice system.
Diversion of people with a mental illness from initial and
deepening contact with the criminal justice system
provides a gateway to care, redirecting people with a
mental illness in need of supports to the services that
can provide them.
Police, for example, have a role in responding to
people living with mental illness in the community but
who are not currently in the forensic system. Under s.
351 of the Mental Health Act 2014, a police officer has
powers to apprehend a person in the community who
appears to have a mental illness to prevent serious and
imminent harm to the person or any other person.
In addition the Mental Health and Police Response
initiative, a partnership between police and mental
health services, strengthens the way mental health,
police and emergency services work together to
provide consumers with timely access to appropriate
urgent mental health assessment and treatment.
Mental Health and Police Response builds on the early
trial of the Police, Ambulance, and Clinical Early
Response (PACER) pilot in Southern Metropolitan
Region, which was evaluated in 2012. The initiative
also complements the pivotal partnership work already
happening between police, mental health and
emergency departments and being supported by local
Emergency Services Liaison Committees that operate
2
in each mental health catchment across Victoria. These
committees bring together representatives from these
sectors as well as consumers and carers to develop
innovative local interagency planning and service
delivery and provide the forum for planning models of
joint response to people in crisis in the community who
need involvement from both police and mental health
clinicians. Working together on appropriate, safe and
collaborative interventions leads to more effective
communication and informed decisions to intervene
early, minimising harm to the person and to others.
Examples of expected outcomes from the Mental
Health and Police Response initiative include a
reduction in presentations to emergency departments
by police under s. 351 of the Mental Health Act 2014
and a decrease in wait-times for police at emergency
departments. A reduction in ambulance call-outs to
transport people in need of urgent mental health
assessment, treatment and support and an increase in
direct admissions to a mental health bed (via MHaP
Response) are also expected.
Implemented across 12 area mental health service
catchments in 2014–15, the initiative will be
progressively rolled out to all 21 adult area mental
health services in due course.
A review of Mental Health and Police Response in
2016–17 is expected to build understanding of the
impact of the initiative in relation to these outcomes.
The Forensic Clinical Specialist Initiative was
established in 2010 to build capacity in area mental
health services to manage the risks associated with
consumers with offending histories or behaviours, and
improve referral pathways and information transfer
between the mental health, justice and correctional
systems.
The initiative funds 10 positions based in area mental
health services and a program coordinator based at
Forensicare’s community forensic mental health
service.
An evaluation of the program in 2013 found that it has
gone some way in achieving its expected outcomes,
particularly in improving the competency, confidence
and skill of staff dealing with the target client group and
their ability to manage risk.
The courts also play an important role in linking people
with a mental illness to appropriate treatment and other
support services. Court-based initiatives include the
Assessment and Referral Court, Court Integrated
Forensic mental health
Services Program, Court Diversion Program and the
Mental Health Court Liaison Service.
Challenges and
opportunities
Victoria has the second lowest rate of forensic mental
health beds per 100,000 people of Australian
jurisdictions and approximately half that of comparable
international jurisdictions. The number of forensic
mental health beds has not grown since 2000 despite
Victorian population growth and increases in prisoner
numbers.
At 30 June 2014, the prison population reached 6,113
(an increase of 68.7 per cent over 10 years) with the
increase largely attributed to changes to sentencing
and parole laws.
Planning for the Ravenhall prison includes provision for
a 75-bed mental health precinct for the non-compulsory
treatment of prisoners with mental health issues with
high-acuity, step-down and transition care beds.
In addition, the 2015–16 State Budget allocated funds
to build a new 44-bed mental health unit at the Dame
Phyllis Frost Centre, to open by mid June 2017.
These additional beds will expand the current mental
health bed capacity in prisons, but will not directly
provide services to prisoners requiring compulsory
treatment (security patients) or forensic patients, who
will still require admission to Thomas Embling Hospital.
Thomas Embling Hospital is under significant pressure
to accommodate increasing numbers of forensic
patients , security patients (prisoners admitted
compulsorily from prisons), and extremely high-risk
compulsory civil patients who cannot be adequately
managed by area mental health services. The fact that
the number of Thomas Embling Hospital beds has not
grown since it commenced operation and the growing
number of forensic patients requiring treatment has
limited the opportunity for security patients (prisoners)
and high risk civil patients to gain access to treatment.
Similarly, demand from prisons, courts and area mental
health services for Forensicare’s community service
has increased markedly over recent years.
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Policy and program options
recommended that a whole-of-system approach was
required.
There is a clear need to improve the availability and
quality of mental health secure treatment options for
high-risk forensic patients, security patients (prisoners)
and high risk civil patients, and to improve the
availability and quality of mental healthcare available to
correctional facilities and both transitional and post
release environments.
Thirteen recommendations were provided in relation to
strengthening collaboration, accountability and
coordination across the Victoria’s criminal justice
system.
There have been a number of investigations
undertaken recently that have noted the issues of bed
demand and bed shortage within the forensic mental
health system. These include the:
• Victorian Ombudsman’s 2011 report on the
Investigation into prisoner access to health care that
found the level of mental health services available to
the male prison population to be inadequate
• Victorian Ombudsman 2014 Death in custody report
that identified there was a lack of mental health
beds at Thomas Embling Hospital, and only the
most acutely unwell prisoners are receiving
treatment at the hospital. The Ombudsman asserted
that without an immediate increase in forensic
mental health beds, the mental health of some
prisoners would deteriorate, leading to increased
incidents of self-harm and potentially death. The
Ombudsman recommended urgent measures are
needed to adequately care for prisoners with mental
health issues.
Since the 2011 Victorian Ombudsman report, funding
for specialist mental health services in prisons has
increased by over 50 per cent, with the equivalent of
over 22 full-time positions created. As noted, 75 male
mental health beds and 44 female mental health beds
have also been commissioned in the prison system to
provide voluntary in-patient treatment.
Additionally, the Victorian Auditor General tabled his
performance audit into Mental Health strategies for the
justice system in October 2014. The report examined
the effectiveness of planning and coordination for
mental health services across the Victoria’s criminal
justice system, as a foundation for effective responses
to people with mental illness.
The report focused on the wide range of departments
and agencies that will often have contact with people
experiencing mental illness that included the then
Departments of Health, Human Services and Justice,
Magistrates’ Courts and Victoria Police, and found that
some gaps existed in the current system and
Forensic mental health
In 2014, the Victorian Government established the
Criminal Justice and Mental Health Systems’ Planning
and Strategic Coordination Board to provide a forum for
improved inter-agency understanding and
collaboration.
In 2014, prior to the Auditor General’s investigation and
in response to demand issues, the Department of
Health & Human Services led a service planning
project for forensic mental health services to consider
the future of this important part of the mental health
service system.
The objective of the project was to develop a
recommended service configuration for ‘within scope’
forensic mental health services, underpinned by a
clinically effective and cost effective model of care. It
was intended to respond to future service demand,
enable timely access to assessment and treatment,
and support the rehabilitation and recovery of
consumers in safe and therapeutic environments.
The Victorian Government is now examining more
detailed advice to government in regards to options for
increasing forensic mental health beds and community
services capacity. As an interim measure, the Victorian
Government has recently announced an additional $9.5
million to build eight new high-dependency beds at
Thomas Embling Hospital, to better accommodate
prisoners and forensic patients with acute mental
illness (2015–16 State Budget).
Questions for consultation
1.
If services were to be expanded, how would
regional/metro services provide these?
2.
How can public mental health services be best
supported to work with forensic clients?
3.
What sort of support would be best in regional
areas? For example, online support, expansion of
the Mental Health Court Liaison Service or
Forensic Clinical Specialist programs, other
support services, capacity building, or
upskilling/specialised supports.
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4.
In areas where there are prisons, what support
would be useful for those transitioning out?
5.
What is useful and working well now?
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© State of Victoria, Department of Health & Human
Services August, 2015.
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Forensic mental health
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