7 Michelle Moore Department of Occupational Therapy, Department of Health, Free State Psychiatric Complex, Bloemfontein, South Africa Forensic mental health services specialise in the treatment of people with mental disorders as related to legal principles. The word ‘forensic’ (from the Latin word forum) means ‘belonging to, or suitable for, the court or public discussion’ (Kaplan & Sadock 2000).The governments of most countries use the forensic mental health services to divert the person with mental illness out of the criminal justice system and into mental health and social care services. Rogowski (in Creek 2002, p. 491) discusses the British system where difficult mentally ill persons are often found in ‘special hospitals, regional secure units, prisons, young offenders’ institutions or on the streets, often passing from one institution of social control to another’. It is essential that occupational therapists familiarise themselves with relevant acts for the particular country in which they work and update themselves regularly on changes to legislation that may affect them. Acts of relevance in the UK (Legislation.gov.uk 2013) are the Mental Health Act 1983, the Criminal Law Act 1977, the Criminal Procedure and Investigations Act 1996, the Human Rights Act 1998 and the Criminal Justice Act 2003. On 28 May 2012, the Health and Social Care Act 2012 was promulgated. In South Africa, the Mental Health Care Act No. 17 of 2002, the Criminal Procedure Act No. 51 of 1977 and the Correctional Services Act No. 111 of 1998 are applicable (Government Gazette South Africa 2013). Criminal laws and acts deal with the capacity of the accused to understand proceedings as well as the mental illness or mental defect and criminal responsibility. If the court finds that the accused is not capable of understanding the proceedings or is not fit to plead (according to English and Welsh law), the court shall direct that the accused be detained in a psychiatric hospital. Where the accused is directed to such a hospital, the accused may, if he/she is capable of understanding the proceedings so far as to make a proper defence, be tried and prosecuted for the offence. If the court finds that the accused was not criminally responsible due to mental illness, he/she can be found not guilty or directed to be detained in a psychiatric hospital or prison. The accused’s capacity to appreciate the wrongfulness of the act can lead to diminished responsibility and will be taken into account with sentencing (Moore 2005 in Crouch & Alers). The aim of forensic health services is one of care and treatment in different levels, namely, low, medium and high security. In South Africa, secure units are gender specific and also have different units for adolescents and adults. It is evident from various studies done that the majority of people admitted in forensic services are young adult males. Offence types as well as diagnosis are mixed (Rutherford & Duggan 2007). Consistent and cohesive teamwork is essential in the treatment of the patients as all policies and procedures are governed by law. The patient population includes people from all walks of life. Different ages, cultures, diagnosis, level of education as well as different offences can be found and should be taken into account by all team members when assessing and treating these patients (Moore 2005 in Crouch & Alers). Assessment, treatment planning and case discussions should aim to: It is important for the multidisciplinary team to develop a care plan in agreement with the patient and the close relatives. Each patient must still have his/her own treatment plan according to his/her individual needs even though the programme may include individual or occupational group therapy. Activities must aim to improve independence and social skills and may include education courses and leisure activities to meet the needs of the individual patient. In South Africa, Mental Health Review Boards are appointed to assist the multidisciplinary teams with reviews and discharges. In Britain, a team of members of the community who act as non-executive directors of a hospital perform this function and are called the Mental Health Act Managers. These tribunals form independent judicial panels and are responsible for reviewing all applications for discharge as well as appeals. The panel consists of a minimum of three members: a doctor (usually a psychiatrist), a legal member and a lay member with mental health experience. Discharge from detention under the Mental Health Act and information on tribunals is available on the Internet (Rethink Mental Illness 2013). A report on the health status of the patient and a tribunal can be requested as soon as 6 months after commencement of the treatment and then every 12 months thereafter. The treatment of the forensic patient can be closely connected to the views of Mary Reilly (Reed & Sanderson 1999) and her Occupational Behavioural Model. She proposed that occupational therapy should activate the residual forces of the individual and equip him/her with the abilities to perform his/her expected roles and responsibilities in the community. As described in the treatment programme, the patient should be given responsibility and become an active member of his/her treatment team with the occupational therapist as the facilitator. However, occupational behaviour and performance alone is not enough. A structured daily programme is suggested for each step in the rehabilitation process. This gives the patients the opportunity not only to obtain information but also to practise the life skills applicable. Another very common model of practice used in many forensic mental health services worldwide is the Model of Human Occupation (Kielhofner 2008). Occupational therapists link the aspects of the model to practise by determining the values, interests and personal causation of the patient to better understand their habits and roles and then to change his/her ability to perform an act based on new experiences. The occupational therapy assessment determines what motivated the patient to make his/her choices. The evaluation must be comprehensive to determine the values (own standards attached and consequences when not adhered to), interests (perceptions, feelings and emotions that lead to enjoyment) and personal causation (the perceived present and potential effectiveness to act on the world with regard to mental and physical capabilities) (Kielhofner 2008). Habits and roles are often resistant to change, but disturbed by the onset of the mental illness, some relearning or developing of new habits may occur. The occupational therapist uses this assumption to change habituation through sustained practice. By involving patients in structured activities on a regular basis, the occupational therapist aims to reshape occupational abilities and identities in order to create new living experiences based on the mental and physical capabilities. It is important to remember that the environment, namely, the physical, social, cultural, economic and political aspects, has a huge impact on the motivation, organisation and occupational performance of the patient. Occupational performance, the actual doing, the skill, participation, competence and adaptation, is influenced and shaped by the external environment that is continually changing. The occupational therapist in the forensic mental health setting wants to reshape and refine occupational identity and occupational competence that was lost with the onset of the mental illness. Through participation in therapeutic occupations in a consistent manner, the mentally ill patient reaches a level of mastery and becomes occupationally adaptive, and his/her behaviour becomes healthier. The Vona du Toit Model of Creative Ability (de Witt 2005 in Crouch & Alers) is a widely used model in vocational rehabilitation in South Africa. It assists the occupational therapist to describe the occupational performance of a client and clearly explain the effects of the mental illness on participation. The model is useful when the patient cannot participate in standardised assessments and then could be well described to the medico-legal fraternity using levels of motivation and action (Casteleijn & de Vos 2007). The Activity Performance Outcomes Measure (APOM) (Casteleijn 2001) is specifically designed for occupational therapists in mental health settings. It covers eight domains of several items, namely: The APOM enables the occupational therapist to provide evidence of the outcomes of the services, track the changes in each individual patient, determine trends and establish the effect of a specific programme. The tool is easily accessible on the Internet (Activity Performance Outcomes Measure (APOM) 2013). Assessment is an essential component for designing treatment and for measuring a patient’s progress. The occupational therapist must determine the sequence of events in the life of the forensic mental health service user to have a good understanding of his/her volition, habituation and occupational competence as discussed. A thorough and comprehensive patient assessment is an essential prerequisite to the appropriate provision of rehabilitation services. An assessment such as the Canadian Occupational Performance Measure (COPM) as described by Law et al. in 2001 is client centred and appropriate. The assessment can be completed through an interview with the patient, clinical observations in a structured or unstructured environment and participation in activities from different activity spheres. Collateral information from caregivers, close relatives, friends and colleagues must not be disregarded. Information obtained from the assessments made in the different levels or wards (moving from high- to medium- to low-security wards) should be verified as changes may have occurred. It is essential to take into account that a large number of forensic patients experience problems with substance abuse and therefore thorough assessment of behaviour and interpersonal relationships is indicated. Poor emotional insight is a general problem with these patients. Due to the long periods of stay and the movement of the forensic patient through the different wards, ongoing assessment and treatment are recommended (Moore 2005 in Crouch & Alers). The role of the occupational therapist is to ensure that the patients admitted engage optimally in activities in the health establishment or psychiatric hospital. Coordinating a well-balanced programme in the various stages of rehabilitation is mainly in the hands of the occupational therapist, rehabilitation therapists and nursing personnel. Occupational therapy support staff can play a vital role in the treatment programmes of long-term forensic patients.
Forensic Psychiatry and Occupational Therapy
Introduction
Relevant legislation
Models used in forensic occupational therapy
Occupational therapy assessment and treatment planning
Related posts:
Ethics, Human Rights and the Law in Mental Health Care Practice
Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist
Vocational Rehabilitation in Psychiatry and Mental Health
Specific Occupational Therapy Intervention with Adolescents
The Treatment of Eating Disorders in Occupational Therapy
Sensory Integration in Mental Health
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
