“to study the benefits of engaging families and carers of ... · class social work service to...

Churchill Fellow ndash Margy Green

1

THE WINSTON CHURCHILL MEMORIAL

TRUST OF AUSTRALIA

Report by 2016 Churchill Fellow Margy Green Senior Social Worker

The Forensic Hospital NSW Justice Health and Forensic Mental Health Network 1300 Anzac Parade Malabar 2036 +612 9700 3820 +612 439 421 104 Margaretgreenjusticehealthnswgovau

ldquoTo study the benefits of engaging families and

carers of patients in secure forensic hospitalsrdquo

I understand that the Churchill Trust may publish this Report either in hard copy or on the internet or both and consent to such publication I indemnify the Churchill Trust against any loss costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on a website for access over the internet

I also warrant that my Final Report is original and does not infringe the copyright of any person or contain anything which is or the incorporation of which into the Final Report is actionable for defamation a breach of any privacy law or obligation breach of confidence contempt of court passing-off or contravention of any other private right or of any law

Signed Dated


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Table of Contents Key words 2

Executive summary 3

Introduction 4

1 What is forensic mental health 6

2 The evolution of forensic mental health 7

3 Institutional responses to mental illness 9

4 Contemporary forensic mental health 11

a Physical environment 11

b Safety and Security 13

5 Social Work in a forensic mental health 15

a The social work role 15

b Forensic social work 15

c Therapeutic Interventions 16

d International best practice in Family Therapy 18

e Family therapy and restorative justice 22

f Stages of Family Therapy practice 23

g Secondary and Tertiary Victims and Perpetrators 23

h Family and Carer support group 25

6 Summary 26

7 Recommendations 27

a Clinicians 27

b Organisations 27

c Australian Association of Social Work 28

d Universities 28

e Commonwealth and State Government in the Australian context 29

8 Acknowledgement 30

9 References 31

10 Churchill Fellowship Summary of Places and People 33

Key words Forensic Social Work Therapeutic Families and Carers Mental Health Family Therapy


3 9042018 435 PM

Executive summary Working in a forensic hospital is a confronting experience with the complexity of patients and familiesrsquo needs overwhelming at times The Churchill fellowship has allowed me to bring that experience and complexity to light starting with a question ldquoWhat is needed to support families and carers of forensic patientsrdquo My eight-week trip in 2017 visiting seventeen secure hospitals and other relevant organisations in the UK Ireland Canada USA and New Zealand provided many answers and generated more questions to be addressed in the future

This paper presumes families are important While there is no such thing as a perfect family they form the basis of our society The United Nations General Assembly (2018) describes family as ldquothe natural and fundamental group unit of society and is entitled to protection by society and the staterdquo Furthermore the United Nations reiterates ldquofamilies are the basic units of social life are major agents of sustainable development at all levels of society and their contribution is crucial for its successrdquo In particular families of patients in forensic units like many vulnerable families need the support from all levels of government business community professionals and individuals to manage risk and mitigate consequences resulting from family breakdown

Hospitals in NSW are based around medically diagnosing treating and preventing disease The challenge for the thousands of social workers employed by NSW Health is dealing with the breadth depth and complexity of social factors to be addressed in the duration of an admission which are not all health related The World Health Organisation (2018) describes social determinants of health as ldquothe conditions in which people are born grow live work and age These circumstances are shaped by the distribution of money power and resources at global national and local levelsrdquo How social determinants contributing to the events surrounding an index offence are addressed will affect the quality of life on discharge for individuals families and communities The learnings from my Churchill Fellowship highlighted the greatest potential to facilitate positive change was to increase the clinical capacity of social workers as they support families and carers of forensic patients

Churchill Fellowship itinerary September 2017


4 9042018 435 PM

Professor Patrick Parkinson (2011) one of the leaders in understanding families in Australia recommends the importance of the need to strengthen families to prevent deterioration in familial structure The reason I applied for a Churchill Fellowship was to address the overwhelming vulnerability of families and carers of forensic patients by providing world-class social work service to mitigate some of their trauma This report begins with a definition and brief history of forensic mental health and provides a context for the evolution of contemporary issues around culture and institutional responses The report focuses on international best practice for the role of social work and the specific additional requirements in forensic contexts The major part of the report is on therapeutic interventions for social workers to maximise change for patients and their families with a deliberate focus on family therapy to address issues on all levels for victims perpetrators and the community Finally the report finishes with a series of recommendations for social workers as individual clinicians organisations the Australian Association of Social Work educational institutions and both state and federal government It is a call to arms for social work to continue to stand up and advocate for justice and equity for the most vulnerable in our community addressing some of the many social determinants affecting forensic patients and their families

Introduction I am often asked ldquoHow do you work in a forensic hospital as a social workerrdquo and other times ldquoWhy do you botherrdquo Supporting the families of patients in a secure forensic hospital does not disavow the horrific experiences of families of victims of an index offence The enormity of loss is far reaching for patients and their families Most often families of patients are also the victims of the event despite repeated efforts to navigate the system to get the support needed Unfortunately for many it was too late

According to the Australian Bureau of Statistics an index offence is a crime of a serious nature including several classes of crimes ranging from murder to theft The Australian and New Zealand Standard Offence Classification (ANZSOC 2011) explains that an index offence means that while forensic patients have been involved in a matter causing serious

I took this picture at the beginning of my trip knowing I would be spending the next two months in different secure facilities It was an interesting reminder of what it is like for patients in secure forensic hospitals to maintain their dignity while under constant surveillance


5 9042018 435 PM

harm they cannot be found guilty in legal terms as it was determined they did not have the capacity due to their mental illness In New South Wales section 38 of the Mental Health (Forensic Provisions) Act 1990 states that where evidence is given in court which shows that at the time of the offence a person was suffering from a mental illness and was not responsible for their actions the jury must find them lsquonot guiltyrsquo by reason of mental illness (NGMI) Section 38 is based upon the long accepted premise that a person cannot be found guilty of a criminal act where they lack the mental capacity or reasoning to understand that what they were doing was wrong

I was not able to include all the incredible invaluable formative experiences and major learnings from my Churchill Fellowship in this report The plan is for these topics to be presented and published in future articles as I continue to process learn and share the experience of my Churchill Fellowship Three main areas not covered in this report are

a The major learnings around cultural and forensic mental health included seeing first hand a Maori mental health framework and the impact of a treaty for traditional owners compared to Australian Aboriginal people There is a paper in its own right to see the importance of a clinical model so closely intertwined with familycultural and spiritual work and the incredible impact this has for patients and families in a forensic context

b The supports in place for patients and families including peer worker programs or Consumer Consultants or Service Users as referenced in other countries which is having the most profound impact on the system These workers are essential to wellbeing and the program needs further support in Australia This is a specialist area in itself that I just could not do justice to in such a short space of time

c The third area of my Churchill Fellowship to further expound later is in relation to practical family supports This work was truly inspirational and left me deeply moved by such dedicated competent and amazing people that work in Atascadero - California Christchurch - New Zealand and Rampton in the UK It included things like accommodation visitorrsquos centres and hospitality visiting hours family days information packages and family therapeutic leave The reason I did not focus on casework is because social workers already excel at this and I wanted to focus specifically on therapeutic interventions which is the area for growth

This report prioritises the need for effective family focused recovery by social workers in secure mental health facilities The report investigates the gaps of therapeutic family work in supporting families and carers in forensic settings It scrutinizes other forensic mental health services in relation to the provision of emotional and social support for families and carers It then canvases the difference between the demands of mainstream social work and the role in a forensic context Furthermore it investigates what theoretical frameworks are used to inform systemic social work practice in forensic mental health settings and the training needed to embed these frameworks in hospital governance According to Herman (1992) the first priority working with people who have experienced trauma is safety this report touches on clinical governance processes for staff to meet the complexity of patients and families need and maintain accountability for safe quality work in forensic settings


6 9042018 435 PM

1 What is forensic mental health For the purpose of this report the most succinct and pertinent description of Forensic Mental Health I uncovered was from Centre for Addiction and Mental Health (CAMH) in Toronto Canada (2018) CAMH define the forensic mental health system as the place where the mental health system and the criminal justice system meet CAMH describes people who have a mental illness and come into contact with the law as becoming involved with the forensic mental health system lsquoForensicrsquo denotes a connection to the law or the courts People who have a mental illness and who come into contact with the law have special needs The mental health system or the criminal justice system alone cannot always meet those needs The Forensic Hospital where I have worked since 2015 is literally a meeting place between the two systems Located next to Long Bay Correctional Centre in the eastern suburbs of Sydney it was the first high secure forensic environment in New South Wales Opened in 2009 as a 135-bed facility it comprises six wards with an adolescent and a womenrsquos unit and four male units covering acute subacute long term and rehabilitation

Similar to other NSW Health hospitals The Forensic Hospital operates from a multidisciplinary model including medical nursing and allied health It has dual goals of patient recovery and risk reduction for patients families and the wider community Government legislation in Australia and internationally highlights the need for working inclusively with a patientrsquos family The NSW Mental Health Act (2007) supports and recommends that treating teams engage with families and carers of all patients in forensic units as opposed to just focusing on the individual `However as this report will show working with families in a forensic setting is a specialist field requiring specific skills experience and training to deal with the complexities around the index offences As outlined in a research proposal I completed (Green 2016) it is important social workers are capable of providing not only practical support but also effective therapeutic interventions to patients and their families This is a crucial part of successful rehabilitation which is contingent upon achieving enduring change in the relational dynamics of families

Artwork on display at the Museum of the Mind UK Lucy McLeod (Miss X) 2003 (Image courtesy of Museum of the Mind London UK 2018)


7 9042018 435 PM

2 The evolution of forensic mental health

The Forensic Mental Health system presents major philosophical challenges around whether to err on the side of risk management or recovery which at times creates ongoing tension getting the balance right Winters (2018) provides a context for this tension in her research on the history of solitary confinement Her work demonstrates how crime was mostly punished by death public torture and shaming in colonial times Moving onto the 18th century where abolition gained popularity the death penalty decreased and sentences become less public Then in 1790 Philadelphia built the first prison with a Quaker philosophy ldquoWhen you sin isolate yourself to fix what happenedrdquo Following on in the 19th century penology started to grow in popularity and retribution took over from the philosophy of rehabilitation Prisoner abuse was rampant at this time Subsequently the 20th century ushered in the period of work camps and gangs which was a punitive reform philosophy under the guise of rehabilitation Finally in the 21st century the clash between the philosophy of rehabilitation and punishment became more pronounced combined with the effect of closing institutions for patients with mental illness War On Drugsrdquo and Tough on Crime campaigns contributed to a massive increase in the prison population from the 1970rsquos through to 1990rsquos not only in Australia but also in the other five countries I visited as part of the Churchill Fellowship

Emeritus Professor John Gunn is described as ldquoa pioneer in the development of forensic mental health in the UKrdquo was a Professor of Forensic Psychiatry at Kingrsquos College London 1978 ndash 2002 and remains a current member of the Parole Board for England and Wales Gunn expounds the clash between the standpoint of rehabilitation and punishment underscoring the problem of convergence as explained by Torrey (2010) ldquohow quietly but steadily jails and prisons are replacing public mental hospitals as the primary purveyors of public psychiatric services for individuals with serious mental illnessrdquo Gunn notes the enormous concern for prisoners not being able to access proper health care needed to address their issues as prisons were not built to be health care centres The United Kingdom is not alone in the struggle to provide continuity of care across correctional facilities and secure forensic units In NSW contrasted with Forensicare Victoria and the other five countries I visited as part of my Churchill Fellowship patients can unfortunately remain in a correctional facility for extended periods before transfer to The Forensic Hospital This is due to a number of reasons one being limited bed capacity which inhibits the provision of patient centred care This is one of the products of a somewhat fractured forensic mental health system which prevent patients accessing timely and appropriate support for themselves and their families

One of the restored statues by Caius Gabriel Cibber referred to as ldquoMelancholy madnessrdquo which was one of the main diagnoses at the time and used to adorn the sandstone gates of Bethlem Royal Hospital 1700rsquos The hospital was referred to by the locals as ldquoBedlamrdquo when it was operating as a Lunatic Asylum or hospital for the ldquoCriminally Insanerdquo (Image courtesy of Museum of the Mind London UK 2018)


8

The proactive nature of the forensic mental health system in Calgary Canada by contrast with other facilities I visited provides patients and families with timelier access to specialist family therapeutic interventions in the pre-trial remand phase Conversely in NSW while they have access to medical and nursing access to allied health is not available until after trial This can result in a person accused of a crime incarcerated for years before they can receive holistic specialist therapeutic allied health intervention The Calgary system creates the potential to move patients through by increasing the social and emotional capacity of a patientrsquos a support system Clinicians experienced in family therapy have the capacity to facilitate posttraumatic growth for patients victims and families having reached greater levels of recovery This in turn has a significant impact on bed flow

Gaining a deeper understanding of tension between the mental health and the criminal justice systems was one of the major learnings of the Churchill Fellowship Most of the facilities I visited had seclusion rooms When considering the use of mechanical constraints there is a tension between human rights standpoints and safety imperatives This is in the context of patients presenting with extremely dysregulated behaviour with a potential risk of serious harm to themselves and others I was inspired to see facilities recently refurbished reducing the number of seclusion rooms replacing them with sensory alternatives helping lower levels of agitation and aggression which can lead to risky behaviour The few remaining seclusion rooms were filled with light from a courtyard overlooking gardens As it can be difficult to discuss seclusion and restraint it is vital to have experienced social work supporting patients and families at this time To people who do not understand risk danger and fear for onersquos life when living with people with treatment resistant mental illness it can appear radical but learning to understand at times it can be the least intrusive option and reassure patients and families and services are doing all they can to assist with their rehabilitation

ldquoPray remember the sick and poor and put your charity into this box with your own handrdquo Set days were open for public visiting to Bethlem Hospital with donation boxes placed by the doors as visitors were required to give money The hospitalrsquos governors encouraged visiting to promote sympathy for and understanding of the lsquolunatic poorrsquo from well to do residents of London It remained in place until 1770 when unrestricted viewing to the public was ceased (Image courtesy of Museum of the Mind London UK 2018)


9

3 Institutional responses to mental illness The Museum of the Mind (MOM) in London UK was one of the highlights of my trip and helped me to understand the evolution of mental illness in a Western context Opened in 2015 on the site of the former Bethlem Hospital the museum uses experiential education to portray a history of mental illness in the UK Historical displays include padded walls straight jackets dresses and braces collars and other mechanical restraints of various kinds needles and jars of medicine from paraffin to camphor as well as old medical texts titled Lunacy Practice and Mental Deficiency to reflect how language has changed Pictures from patientsrsquo art therapy elicit an array of emotions from the viewer from admiration to pity intrigue and shock

Museum of the Mind Curator Colin Gale explained to me one of the best ways to understand history is through various case studies of patients Similar to today some patients were extremely well known with tabloids creating strong opinions about what should become of such people One infamous case involved James Hadfield who attempted to assassinate King George III in 1800 but was acquitted of attempted murder due to insanity and subsequently incarcerated in Bethlem Hospital until his death The Hadfield case prompted the British parliament to pass the Criminal Lunatics Act 1800 in order to detain the mentally ill In a similar case Daniel McNaghten intended to murder the Prime Minister but mistakenly killed the Private Secretary instead He was found not guilty due to mental illness and taken to Bethlem The McNaghten case was important as the judge laid down a set of principles in his trial in 1843 These became known as the McNaghten Rules designed for assessing the intended capacity for criminal intent Britain the Commonwealth and other countries throughout the English-speaking world still use the McNaghten Rules to determine intent The third story involved eighteen-year-old Edward Oxford who acquired a pistol to wait for

This shows some of the old psychiatry textbooks with titles such as lsquoLunacy Practicersquo (Image courtesy of Museum of the Mind London UK 2018)


10 9042018 435 PM

the Queen and fired a few shots The bullets were never found so uncertainty remains whether the gun was loaded Oxford was found ldquonot guilty by reason of insanityrdquo and detained at Bethlem The newspapers of the day expressed the populist view Oxford ldquoshould be hungrdquo but there were differing viewpoints informed by clinical observations at Bethlem on his admission During his twenty-year stay at Bethlem Oxford learned to play the violin became fluent in three languages decorated the hospital walls as a painter and attended lectures by George Hayden Bethlem Hospitalrsquos Steward Hayden had been to Australia on earlier explorations as an illustrator and when he returned to Britain and gained employment at Bethlem hospital he gave lectures about his time on these expeditions When Oxford received a conditional pardon to leave the UK in the early 1860s he took a one-way trip to Australia changed his name married and became a journalist in Melbourne He kept in touch with Hayden and the letters still exist in the National Archives of Australia

The demand for high secure forensic hospitals in Britain grew throughout the 20th century After the establishment of Broadmoor hospital in the early 1860rsquos a second facility opened at Rampton in 1912 followed by Carstairs in Scotland in 1948 The fourth high secure facility opened in 1990 at Ashworth Key landmarks included the Butler Report in 1975 which was pivotal for integrating mental health services with the National Health Service This encouraged the early transfer of patients with a mental illness to hospital and proper after care for offender patients as the key to avoid impeding the prison system

This picture reminded me how far we have come in the provision of support for those with mental illness

(Image courtesy of Museum of the Mind London UK 2018)


11

I reflected at the close of my visit to Museum of the Mind on how the issues of today continue to resemble the concerns from centuries ago such as

bull The appeal for people to contribute financially is echoed in contemporary challenges ensuring adequate funding and budgets to provide adequate services

bull Conversely there is a stark contrast between contemporary usage of language to label describe and categorise patients to minimise stigma and the early days of forensic mental health

bull The importance of therapeutic alliance we identify today was evident historically in the relationship between Oxford and Hayden which can be life changing

bull The issue of governance as a challenge was demonstrated with the appointment of the first resident physician Charles Hood in 1852 to address issues of rampant abuse happening at this time Improving governance remains an ongoing concern in forensic mental health

bull The importance of offering a range of alternate therapies was identified early in the history of forensic mental health This focus became honed through the development of allied health disciplines today

bull The imperative to educate the media to mitigate their perpetuation of stigma remains as important today as in the time of Oxford when the media wanted ldquoto hang himrdquo as the response from the community can significantly impact a patientrsquos recovery

4 Contemporary forensic mental health The historical tensions between risk and recovery are still evident today in contemporary forensic mental health This can be evident in relation to issues such as physical environment security and safety

a Physical environment When you exit the Museum of the Mind you are surrounded by exquisitely established and maintained gardens of Bethlem hospital This was consistent with the philosophy of these special hospitals to be places of rest to restore a personrsquos body mind and soul The Prudence Skynner Clinic which I also visited in London was likewise located on a former asylum site and has only recently been converted to a golf course with the surrounding breathtaking beauty of the trees green meadow and gardens

Some of the old medicine bottles used at Bethlem Hospital



12

Broadmoor hospital is physically inaccessible with a new building opening in 2018 I was able to see the old hospital in front of which is a long rectangular building specifically built on a rise with a grassy area out the front It was purpose built with patients knowing they were not going to be discharged for some time It was designed for them to have access to beautiful green rolling hills looking out the back of the hospital where you couldnrsquot see any walls and was easy to imagine being in the countryside The ground drops away very steeply at the back of the hospital and there is an enormous fence at the bottom of the hill out of sight This was deliberate on the part of the hospital authorities as a way of holding a space whereby patients knew they were patients but not criminals allowing some movement within the hospital

Over the last decade The Centre for Addiction and Mental Health in Toronto Canada had invested a large amount of time and money into a campaign to address the stigma of forensic mental health Part of this strategy meant taking down the walls around their facilities to open up as public parklands There is a remnant of the wall left in place signifying these times and attitudes back then and how instrumental attitudes to security are softening The current economic climate means an increase in the demand for more work with less funding There is limited capital across the sector to invest in large grounds with manicured gardens but there is potential for creative use of existing physical space to incorporate therapeutic principles into green space available Carstairs in Scotland and Central Mental Hospital in Dublin utilised nursing positions to start a small farm and vegetable garden as a way to support patients with recovery

Picture from Centre of Addiction and Medicine in Toronto Canada showing where the wall has been taken down to open the grounds up to the public as part of the campaign to reduce stigma for forensic patients

Picture from Centre of Addiction and Medicine in Toronto Canada showing adjustments to the height of the wall at different periods


13

Alex McLean Senior Charge Nurse Rehabilitation The State Hospital Carstairs Scotland and previous UK Churchill Fellow is a brilliant example of this work Nearly a decade on the fruits of her labour can be seen in getting patients off the ward into the sunshine doing physical activity and interacting in a more socially positive way with staff and peers and family

b Safety and Security With the current economic climate there is a need more than ever to maximise the use of limited resources Staffing costs are by far the biggest expense in running a hospital therefore the importance of having the right staff in the right place at the right time is crucial to avoid wasting resources The exemplary standard of forensic mental health services in New Zealand is due to the experience of people like Dr Rees Tapsell Executive Clinical Director of Midland Regional Forensic Psychiatric Service Tapsell is a psychiatrist who identifies as a Maori This brings the benefit of a cultural lens to his work in providing a Maori specific forensic unit in Hamilton Tapsell shared his reflections and experience of contexts that have been staffed appropriately increasing patient outcomes and likewise having seen when this was not the case I also met with Dr Derek Wright Executive Director Mental Health and Addictions Services Waikato District Health Board New Zealand who after decades of experience working in both Australia and New Zealand in forensic mental health emphasised more staff is not necessarily the answer Rather to address issues of safety requires having the right staff with the right qualifications and ongoing access to appropriate training including a culturally appropriate workforce Wright referenced meeting local Maori needs but also generalised from his experience about the link of investing in workforce to maximise safety and security

This is at the front of the hospital at Hamilton New Zealand This picture shows the connection between the forensic hospital and the mainstream psychiatric facility on the other side which is indicative of their close working relationship


14 9042018 435 PM

Professor Sandy Simpson Clinical Director Centre for Addiction and Mental Health (CAMH) in Toronto Canada reiterated similar sentiments around workforce issues in Forensic Mental Health Simpson was part of the New Zealand Ministry of Healthrsquos Mason inquiry that made the decision in 1998 to close a national high secure forensic facility because it was operating contrary to their philosophy of keeping patients close to their family The values led stance of the New Zealand government may in part explain why they have a reputation as a world leader in the provision of forensic mental health services (Fairly 2007) Professor Simpson emphasised that adequate staffing levels create a greater presence and opportunity to manage safety around interpersonal relationships instead of rules He stressed ldquoWhen a priority is placed on staffing appropriately apart from being able to do more therapeutic work it means only in high risk situations is there a need to call in for additional servicesrdquo Since The Forensic Hospital opened in 2009 in NSW there has not been access to readily available social workers with forensic mental health experience and finding such staff remains an ongoing challenge It takes years to develop the requisite experience skills and knowledge base for a forensic mental health setting Without the necessary experienced social workers there are implications in meeting the nuanced challenges demanded in development and implementation of policy and procedures and to underpin clinical interventions As a result policy is developed predominantly from available disciplines thus inhibiting a holistic service provision for patients and their families It is critical for there to be workable patient to staff ratios in this environment to avoid compromising relational security As the proportion of patients to staff increase the capacity to contribute meaningfully to patient recovery is diminished In my research I noted the staff to patient ratios varied across the domains underscoring the importance of having a workable balance for best outcomes by other clinicians to ensure a sustainable strategy

This is a picture of New York City the morning of the day of 911 before the events took place at the World Trade Centre that changed the world on display the Ground Zero Museum in New York

It is symbolic of how patients and families lives are turned upside down after an index offence The picture of life lsquobeforersquo is a stark reminder when the memory of lsquoafterrsquo is so firmly ingrained People wonder if life can ever return to lsquonormalrsquo


15 9042018 435 PM

5 Social Work in a forensic mental health a The social work role

The function of any hospital is to provide appropriate treatment and care that cannot be provided in the community Many patients have needs and problems that may be contributing directly to their illness but cannot be met exclusively by medical interventions Among these needs and problems are those arising from relationships family and financial difficulties Personal problems of this nature are more likely to be present among those suffering from mental disorder (Lewis 1999 27) One of the key roles of social workers in a forensic hospital is to support patients families and carers to understand the circumstances that contributed to the patientrsquos admission so they know how to prevent it from reoccurring Working as part of a multidisciplinary team the social work role includes

Assessment Involves a thorough biopsychosocial assessment covering individual strengths challenges and resources available to assist their recovery to inform sustainable discharge and reintegration into community Counselling Emotional support for both individuals and family covering areas of adjustment development of social skills grief and loss addiction insight compliance self-esteem and victim support Liaise advocate and refer Working with the patient to determine their goals and facilitate access to resources linking them with community based services to support the recovery journey These services can include cultural issues immigration legal aid child protection Work Development Orders among others Psycho Education This can be for families and patients to help them understand the illness the medication or legal processes

b Forensic social work The National Association of Forensic Social Work (NOFSW) established over twenty years ago is the only peak body internationally representing forensic social work I organised my Churchill Fellowship around the annual NOFSW Conference held in Boston in 2017 to complete the first accredited advanced ldquoForensic Social Work Certificaterdquo program I was fortunate enough to do this training with the only other Australian to complete the course veteran social worker Sue Foley Director of the NSW Childrenrsquos Court Clinic Having Sue there enriched my experience through her sharing of her established network of forensic social work contacts It also supported my process of adapting my understanding of forensic social work to an Australian context Dr Stacey Hardy-Chandler (PhD JD and LCSW) from Fairfax County Department of Family Services Las Vegas facilitated the Forensic Social Work Certificate program Dr Chandler is a founding member of NOFSW and was able to chart the history and foundations of forensic social work in the USA The NOFSW defines Forensic Social Work as ldquothe application of social work to questions and issues relating to law and legal systemsrdquo One of the statements that particularly resonated with me in relation to an Australian context


16 9042018 435 PM

was when Dr Hardy-Chandler explained ldquoPractitioners are often putting the cart before the horse and they get a job in forensic social work and then need to find the training to equip them to do the rolerdquo The NOFSW (2018) explains ldquoForensic social work is based on specialized knowledge drawn from established principles and their application familiarity with the law painstaking evaluation and objective criteria associated with treatment outcomesrdquo Forensic social work is about much more than mental health it includes social work practice in any way related to legal issues and litigation Apart from the application of social work theory to practice social work in forensic contexts requires a broad application of legal knowledge including criminal and civil matters from child protection and supporting those connected in any way with the justice system I reflected on why social work was not more engaged with the justice system and further research by Reamer (2008) revealed how the social work profession has largely abandoned the criminal justice field suggesting this decline was at least partially due to professional resistance to working in coercive settings with involuntary clients It is crucial that this change

One of the major learnings of this Churchill Fellowship was acknowledging the majority of social workers employed in NSW state government such as the Department of Health or Family and Community Services work forensically they do not claim the title of Forensic Social Work Social work unlike other disciplines as psychiatry and psychology further develop their work as an area of expertise and clinical speciality The Certificate in Forensic Social Work and connection with NOFSW enhanced my understanding of how the role of forensic social work can evolve in a more comprehensive way to support families and carers of forensic patients

c Therapeutic Interventions The key aim of my Churchill Fellowship was to develop an understanding on how to support families in forensic mental health Davies et al (2014) argue key advantages of systemic work used in secure settings ldquotake into account the wider social context of the patientrsquos life and is interested in the relationships between the patient their family and the institutionrdquo (Davies et al 2014 521) The Australian Association of Social Work position paper on Mental Health (2012) supports this view arguing the role of family is essential to support patient recovery


17

I had an emerging understanding of the importance of social workers engaging in therapeutic work before prior to my Churchill Fellowship The reason why is because you want to offer the very best possible support to empower patients and families to maximise change and to avoid patients being readmitted after they have been discharged I am now more convinced of the imperative for social workers to have high levels of qualifications and experience in counselling One of the keys to providing appropriate counselling is having a firm grasp of the principles of family therapy

ldquoSocial work practice today in its many different forms and contexts still need to employ counselling as a possible method of intervention in specific and appropriate contexts at the same time drawing on counselling theory more generally Without counselling theory and counselling skills social work practice is likely to be ineffectual and inefficientrdquo (Brown 2002 p 141 in Flaskas (2007)

I chose systemic family therapeutic interventions to inform practice in the context of the highly personal and relational aspects of a patientrsquos index offence I believe experience and education in family therapy is foundational to optimise therapeutic interventions and achieve the greatest outcomes for patients and their families The use of systemic family therapy provides a more holistic approach to treatment in the way it moves from being concerned with the nature of the conditions of the human mind to a broader understanding of the relationship between parts of a wider system (Gibney 2003) All index offences have relational aspects likewise it is in the context of relationships that a patientrsquos recovery happens Because of the complexity of relational issues such as neglect abuse addiction homelessness and violence it is vital that the skills and experience of relational experts in family therapy such as social workers are matched to the complexity of the patients and familiesrsquo contexts to carry out appropriate interventions

This is a picture of a piece of steel structure from the foundations of the World Trade Centre on display at the Ground Zero Museum in New York No one ever imagined when this was built something so strong could ever be broken It represented to me what it must be like families with the admission of their loved ones to a forensic hospital ending up in a situation they never dreamed possible in their worst nightmare


18 9042018 435 PM

Confirmation of the importance of a systemic family therapy approach came during my visit to Ashworth which is one of the four high secure facilities in the UK Amanda McBride Senior Forensic Social Worker and Carer Lead of the Secure Division has developed an exceptional psychosocial education program for carers and families to enhance their understanding of treatments and interventions available to their family member whilst in secure care This empowered families with knowledge and understanding challenging stigma promoting positive working relationships with families and addressing power balances

What stood out for me in listening to the work McBride had undertaken with families were her reflections of ldquothe need for advanced clinical skills to increase a familyrsquos capacity to deal with the issues at hand to make a more sustainable differencerdquo Despite demonstrating international best practice through ensuring every possible support was in place from a case management perspective when I asked what one thing she would change if given the opportunity she nominated ldquomore specialist clinical skills working with families to address the complexity of the relational dynamics you are confronted with supporting families in forensic mental healthrdquo This is consistent with Poon et alrsquos (2013) findings that ldquosocial workers who are skilled in family work play a key role in assessing the burden of caregiving and provide family interventions to support caregiversrdquo (Poon et al 2013 161)

d International best practice in Family Therapy

Annie Turner ndash ldquothriving in an age of austerityrdquo

While my focus was on working in a high secure forensic context I was also able to visit three medium secure facilities in London The first visit was with Annie Turner Head of Family and Couple Therapy and Course Director at the Prudence Skynner Clinic at Springfield Hospital The Prudence Skynner Family Therapy Clinic is a unit within South West London amp St Georges Mental Health National Health Service Trust The service provides family therapy within the adult mental health services The service was established in the mid-1970s and now provides a number of general and specialist clinics Turner had several key strategies for managing a thriving family therapy counselling service in an age of austerity Firstly from her decades of experience she provided supervision to practitioners Rather than charging fees for supervision she was able to get them to contribute to being part of her reflective teams A reflective team is a different type of therapeutic work with a lsquotherapistrsquo and an lsquoaudiencersquo of other clinicians The location of the audience can be varied from the invitation I had to sit in a room behind one way glass used by Prudence Skynner Clinics or alternatively in Albert Psychiatric Hospital Calgary sitting in a room with the therapist and patient to observe the discussion with the family members thousands of miles away linked via audio visual There are several parts to the process with the initial meeting between therapist and family members The second part then involves family members observing sharing of reflections between the therapist and observing clinicians to open up to new possibilities and ways of seeing things as they are invited to hear themselves being talked about This is followed by another discussion between the family members and therapist in light of the new information they have heard followed by final


19 9042018 435 PM

questions and a debrief with clinicians as they working on hypothesis to assist shaping their questions (White 1995) The Prudence Skynner Clinic arrangement suited many Family Therapists who had entered private practice to maintain contact with other professionals working as part of a team There were only two full time staff at the clinic and the rest were volunteers Turner also ran training courses in family therapy that contributed to an income for the service and allowed them to be self-sustaining The service to families without charge as it is part of the National Health Service with the only criteria for referral that one member of the family had a problem with mental health

Maeve Malley ndash ldquoChallenging myths individualist structures and hoperdquo

The medium secure facility at Bracton London was particularly significant enabling me to meet the family therapist veteran and clinical Psychologist Dr Maeve Malley Malleyrsquos most recent connection with the hospital was in the capacity of providing systemic supervision to staff She has many years of working in different facilities including mainstream womenrsquos correctional units Malley discussed the challenges in forensic mental health where so much emphasis is placed on individual work and not enough emphasis placed on working families Malley explained individual diagnostic practices across all levels of mental health services have become privileged This in turn has perpetuated intensely individualistic practices in current mental health services negating relational family work and subtly and not so subtly shape the services offered

This is one of the emergency vehicles on display at the Ground Zero Museum in New York It is symbolic of how even the most well equipped workers are not exempt from coming under fire and burning out if there are not adequate strategies in place for protection


20

Malley confirmed a misconception in the sector that forensic hospital staff have all the time in the world to treat people compared to mainstream acute mental health facilities which have a higher turnover of patients Often acute wards have a much higher staff to patient ratio to address needs in the shorter term and the needs are mostly less complex to address Maeve shared her reflections on evidenced based practice that the evidence needs to be in everybodyrsquos interest not just the funders or the clients She also challenged preconceived ideas about ldquocurerdquo being an unhelpful concept and comparing mental illness to physical illness because mental illness is its own separate category with specific dynamics

Riordan (2016) reiterates the importance and benefits that forensic psychotherapy has to play in the management of mentally disordered forensic patients One of the most important points Maeve highlighted for organisations and professionals was the amount of additional training needed to work psychodynamically Malley was aware of the challenges for staff including the accumulation of trauma affecting onersquos work The significant challenges for staff in a forensic mental health setting cannot be addressed without appropriate clinical governance that provides a safe accountable and quality service An organisation without appropriate clinical governance in place carries the danger of putting patients staff and the organisation at risk This is particularly pertinent for environments where there is a high exposure to trauma Safety is a physical and psychological issue It is imperative to have risk management in place to ensure staff have the skills and qualifications and that they are working within their scope of practice Regular supervision by appropriately qualified and experienced clinicians who are also accountable for their own work is also key If appropriate supervision is not in place there is the risk of boundaries becoming compromised and staff taking on more than they should emotionally resulting in vicarious trauma and losing the capacity for empathy for patients A commitment to ongoing professional development and support is vital This includes adequate training to ensure clinicians develop the skills set to meet the complexity of the needs of patients

This pile of rubble from the remains of the World Trade Centre on display at the Ground Zero Museum in New York is symbolic because I imagine what it must feel like for patients and their families left behind in the wake of destruction that often comes with an admission to a forensic hospital


21 9042018 435 PM

Jo Bownes ndash Founder of the ldquoWelcome Meetingsrdquo

In London I met with Jo Bownes Social Worker and Family Therapist on the Wells Unit a secure inpatient unit for adolescents in West London National Health Service Jo has set an international benchmark over the last decade in her work with adolescents and their families She created and developed the ldquoWelcome Meetingrdquo A ldquoWelcome Meetingrdquo is the process of introduction for the patient and family to the ward and the team of professionals they will be working with throughout their admission The meeting aims to be in the first two weeks of admission and is chaired by any clinician on the treating team The meeting is not a chance for professionals to gather information from the family but an opportunity for the patient and family to ask questions so they can understand the roles and responsibilities of the team looking after them to help them orientate It covers things such as explaining about the unit and basic logistics and routines therapeutic aims and the process finishes with an agreed way for everyone to keep in touch to implement the treatment plan ldquoWelcome Meetingsrdquo are based on principles of family therapy That is clinicians not coming in with an agenda but finding out what the family understands as helpful as the starting point The Welcome Meetings are a way to shift culture Bownes explained but she also reinforced the need for appropriate qualifications and the confidence and competence to expand these valuable services Bownes work is testimony to her passion and commitment and core social work values such as social justice Despite the international effectiveness of the ldquoWelcome Meetingsrdquo one of the hardest lessons I learned was the assumption you are not necessarily greeted with support with the implementation of innovative ways of best practice In fact designing new ways of providing treatment can be misinterpreted as a threat or risk by clinicians challenged by the concept of change This is despite enormous personal cost in carving out a niche when there is no one who has gone before with a similar model Clinicians open themselves up to criticism and do not necessarily have the support from those who should be their greatest allies Bownesrsquo leadership ability tenacity and commitment are a credit to her and the character needed to persevere despite such strong resistance to change

ldquoAsk and Get no reassuranceldquo Charlotte Johnson-Wahl 1974



22

e Family therapy and restorative justice

I had the opportunity of observing first hand international best practice in engaging families of patients in a high secure hospital through a session facilitated by Professor Sergio Santana Clinical Director Alberta Forensic Mental Health Services and Associate Professor of Psychiatry at the University of Calgary Santana is a psychiatrist and a family therapist trained at both Prudence Skynner clinic in London and Calgary Family Therapy Centre founded by Professor Karl Tomm His work is eminent because it combines family therapy in a high secure forensic setting with the principles of restorative justice His family therapy work includes a multidisciplinary team relying heavily on the role of social work Canada has a similar geographical context to Australia with the challenges of distance Santana has worked to alleviate the difficulties of distance through audio-visual link up

Santanas approach using family therapy pre-trial in forensic mental health is ground breaking His work creates space for reframing adjustment from a new reality which has been defined by the medico-legal experts as a result of the index offence This process is especially helpful for patients in a forensic setting in their recovery because as Govier (2002) explains it helps patients move through a process from ldquoshame and guiltrdquo but also prevents families ending up stuck in a position of ldquoblame and fearrdquo The reason it is so important to start this work early and not leave it for years is to prevent a calcified position for the family Often the only option for expressing the victimrsquos voice is a victim impact statement which usually happens years after the incident when the trial has finished While it is vital for the victim to have a voice (even when the victim is also a family member) what can be even more powerful in healing from trauma is connecting the victim through a dialogue with perpetrators to create a new reality

This is a picture of a worker cleaning up in the aftermath at the World Trade Centre on display at the Ground Zero Museum in New York It is symbolic because it reflects the rebuilding and recovery journey of families in putting their lives together after an index event


23 9042018 435 PM

f Stages of Family Therapy practice Santanarsquos process for working in a forensic mental health setting includes four stages in the family therapy process

a) Firstly it is about working with the patient until they are medically and emotionally stable

b) The second stage involves simultaneously working separately with the family to address issues of blame and fear The first two stages are long and slow and may take up to several years of meeting with families every six weeks Once the first two stages are complete the final two stages appear to move along more quickly

c) The final stages draw on Whitersquos (2007) principles of narrative therapy in the form of a letter from the patient to the familyvictims acknowledging responsibility and understanding of the impact of the events

d) Depending on the outcome of the letter there will be a transition to an audiovisual link up to allow the family to meet the person The audiovisual link up allows this to happen in a controlled manner as both parties are in separate geographical locations

In Santanarsquos experience once the initial audio-visual contact happens it tends to trigger memories that ignite willingness for both parties to have the courage to see each other in person Extensive work with both family and patients negates the likelihood of them getting to the point of polarisation The therapy team will continue to address ambiguity in a contained environment allowing both parties to express and acknowledge each otherrsquos experiences Ambiguity is often expressed through families having a fear of the release of their loved ones and patients fear the burden of guilt to carry for the rest of their lives

g Secondary and Tertiary Victims and Perpetrators There is a vast amount of lives impacted as the result of one index offence For example staff in mental health facilities ambulance officers transporting victims police as part of arresting and detaining the perpetrator the neighbours who may have heard or seen what happened the chemist who prescribed medication the teachers at the school where the children attended to name a few One of the questions I asked many of the professionals working in this sector was whether there was opportunity for community healing and recovery and the role of the perpetrator in this Santanarsquos work reminds us of the importance of working with more than just the individual and the language he uses to explain this second order change which takes recovery to another level It is about broadening our lens away from focusing on the individual instead viewing the individual in the context of relations to others and their system Santana helped me expand this idea from Govierrsquos (2002) theory involving three types of victims and perpetrators


24 9042018 435 PM

Three types of victims

1 Primary Victims ndash 60 of the primary victims are family members and often the deceased are mothers (MacInnes 2000)

2 Secondary Victims ndash relatives and friends of primary victims ones left behind 3 Tertiary Victims ndash community and society and many people affected by the index

offence as mentioned above Three types of perpetrators

1 Primary Perpetrator ndash person who committed index offence 2 Secondary Perpetrators ndash people who have influence but chose to not be involved 3 Tertiary Perpetrators ndash political and economic influences

This model provides a context to explain how the implications of an index offence are far reaching but also systemically how the recovery process is about more than primary victims and perpetrators It references the tertiary level of silence in not addressing political and economic issues that can contribute to and result from the events This was consistent with my experience working with Victims Support Services at the Forensic Hospital in Sydney This challenges the fragmentation of the current system whereby we are constrained to work separately with victims and perpetrators which can inhibit some restorative work

Person with severe mental illness (SMI) ldquoshame and guiltrdquo

Victim of offence ldquoblame and fear

Professionals working restoratively

Index event

Family amp Carers

Community

Systemic model designed from the principles of Govier (2002)


25 9042018 435 PM

h Family and Carer support group One of the greatest displays of peer support was the Family and Carer support group at the Central Mental Hospital Dublin It was held in a wooden shed crammed with couches and an old white board This room was normally freezing but by the end of the session with over twenty family members crammed in for the monthly meeting it was hot The group evolved from Chief Social Worker Pauline Gillrsquos initiative After reflecting on the challenge for families to come through the front gates she tried calling some of them to talk about the issue but never got her phone calls returned She then proactively sent them a letter to ask for the feedback and was again met with silence It was only when she physically left her desk and walked to the front gate to meet families and carers to acknowledge in person ldquohow difficult it must be to come hererdquo that she started to build the connection with families The challenge of emotionally getting through the front gates referred to by locals as lsquothe gates of hellrsquo was a pattern for many families and carers It is this human connection that encapsulates the support group she established twelve years ago with at least twenty people at a time coming from across the country which for some means getting up at 400 am to make it in time People did not want to miss the chance to draw some comfort and hope with others who have trodden the same path This support group personified excellent forensic social work Like other allied health disciplines social workers do not have the luxury of having set times for set periods in a specific allocated room Some of the best therapeutic interventions from social workers can be at the most inconvenient times in the least likely places Families are often unable to get through the front gates of the hospital because of the pain and the stigma and array of other emotions associated with their experience of their family memberrsquos index offence In this case it is crucial for social workers to adapt their practice to meet families where they are at and then to support them throughout the admission to minimise the disruption to their lives The courage and support this group of people were able to give and receive from each other was nothing short of inspirational Social Work Manager Pauline Gill and her successor Donal OrsquoMalley were consummate professionals in being close enough to the edge to support the group but letting it take a life of its own While typical of social work style neither of them wanted to know about any kudos for the group there is still much learning from her approach and for so many families around the world

This is the entrance to Central Mental Hospital Dublin If you note the small gate at the side is the one you walk through it puts into perspective how large and daunting the other gates can be for families coming to see their loved ones If you look closely you can also observe the difference in the heights of the wall where it has increased at different times in its history


26 9042018 435 PM

6 Summary The Churchill fellowship gave me a unique opportunity to see how past learning is incorporated into best practice in the future I experienced firsthand a centralised forensic mental health facility with over a thousand patients and debated with professors the challenges of mass incarceration in the USA I witnessed world-class patient centred care in Canada I was inspired by the positive impact on families having accredited and licensed family therapists and clinicians practising in high secure environments in Canada and USA I saw the benefits of universities collaborating with hospitals to increase outcomes for patients and their families in Vancouver and Melbourne I celebrated the success in Vancouver and Dublin of allied health providing therapeutic services in correctional facilities for the first time I was also able to share the joy with so many social workers and other senior mental health clinicians of knowing that their work alleviates the burden on patients families and the wider community As Professor Harry Kennedy reminded me ldquothe goal of forensic mental health is not about reducing recidivism but about treating mental illness which reduces recidivism as a resultrdquo Implementation of a system that provides appropriate rehabilitation to work with families with histories of experiencing trauma takes a lot of work It takes more than having an inquiry more than having allied health appointed to senior government positions it takes more than having adequate staff in the positions and appropriate funding What it takes is having the right people with the right qualifications and the right experience at the right time There needs to be the right infrastructure for people to perform their roles and the right measurements in place to ensure accountability and produce agreed outcomes If any of these elements are not in place the patientrsquos recovery is compromised The experienced international clinicians working in this sector taught me to persevere and keep sight of the goals and values of the social work profession It is my aim that the experience I gained first hand may be of wider benefit to the profession in New South Wales and Australia As an outcome of my Churchill Fellowship I hope to facilitate networking opportunities through conferences training and collaboration

This is a pear tree outside the front of the Ground Zero Museum in New York It was a small sapling which survived 911 Somebody took it home nurtured it and then transplanted it back to remind people of the reality of recovery in the midst of horror if you have the right supports


27 9042018 435 PM

7 Recommendations The aim of this report was to focus on improving support for families of patients in high secure forensic environments Given the sensitive nature of forensic work internal recommendations are not public The following general goals and recommendations are for clinicians organisations government departments universities and peak bodies

a Clinicians 1 Objective For the peak organisation the Australian Association of Social Work

(AASW) to have the power to drive the necessary change for the profession i Recommendation For compulsory membership in the peak body (AASW) of social

workers

2 Objective To align social work with other allied health professions with compulsory accreditation as a matter of urgency to increase governance ensuring long term viability and accountability of the profession i Recommendation To advocate peak body and government for mandatory

accreditation for the social work profession

b Organisations 1 Objective To facilitate information sharing and ensure evidence based best practice by

increasing networking with international organisations such as i International Association Forensic Mental Health Services (IAFMHS)

ii National Organisation of Forensic Social Work (NOFSW) in the USA iii International Federation of Social Work (IFSW)

a Recommendation Financial support to ensure funds and time are allocated for

access to publications and participation to attend andor present at international conferences focusing on forensic mental health andor social work supporting families

2 The peer workforce is a growing area in mental health with tremendous benefits

increasing recovery for patients and their families Objective To replicate the model designed by the Chief Social Worker and Senior Consumer Consultant at Thomas Embling Victoria setting an international benchmark for work in this area to maximise support and protection for patients family and workers interfacing with a health organisation in a forensic environment

a Recommendation Social Workers experienced in trauma informed care to be involved in the development implementation and evaluation of a peer workforce


28 9042018 435 PM

3 Objective Holistic provision of support for families is core to the role of social work including cultural domains a Recommendation For social work to complete and drive a suite of culturally

sensitive training to inform a nuanced understanding of the way mental illness is conceptualised in the personrsquos culture of origin especially Aboriginality

c Australian Association of Social Work 1 Objective For universities organisations and clinicians to develop specialisation in

social work for particular cohorts such as forensic social work with sub specialities in mental health a Recommendation To explore with AASW Mental Health Special Interest Group

to look at developing Forensic Social Work in Australia

2 Objective To register the name of Social Work following the UK Health Care and Professions Council (HCPC) a Recommendation For Australia register the name of ldquoSocial Workrdquo and prevent

anybody practicing under this name if they are not registered

d Universities 1 A consistent theme raised internationally was social work successfully advocating for

patients at the detriment of advocating for their profession Due to time constraints it is challenging to further the standing visibility and respect of the social work profession It is imperative for this to change to keep the discipline viable Objective It is vital for forensic social workers to engage in research to contribute to the evidence and knowledge base in their area a Recommendation Social workers recommended to proactively seek formal

research opportunities and publish findings to develop the role of social work and to focus on the benefits of support for patients and families in secure environments

b Recommendation University assistance for articulation of the role of forensic social work to counter any move to subsume role within generic job descriptions such as Caseworker or Mental Health Clinician

c Recommendation Universities in concert with AASW and Health Departments and Child Protection to conduct a review for specialist forensic social work qualification

d Recommendation Collaboration and development of strategic partnerships with experts in the field to develop research plans utilising student input where appropriate

e Recommendation To nationally standardise the process of recognising clinical social work as per USA and Canada by further education and experience


29 9042018 435 PM

e Commonwealth and State Government in the Australian context 1 There is a strong indication for representation at an executive level for allied health

disciplines within government public health systems to ensure that voices not only reflecting the medical model can be heard to facilitate more holistic practice Objective To have a process in place for increasing the voice of individual allied health disciplines rather than be lsquolumpedrsquo together as one a Recommendation For AASW to advocate for the appointment of permanent full

time allied health clinicians in senior executive government positions to work together with clinicians from medical and nursing to bring a nuanced holistic and balance to policy development and implementation

2 Australian Health Practitioner Regulation Agency (AHPRA) is the peak body for Allied

Health accreditation in Australia which commenced in 2010 and oversees sixteen different allied health professions AHPRA supports the National Boards responsible for regulating the health professions The primary role of the National Boards is to protect the public and set standards and policies that all registered health practitioners must meet The challenge for regulation is for disciplines not regulated by AHPRA working under the NSW Health Professionals Award (which Social Work in NSW hospitals operates) a Recommendation For AHPRA to review allied health professions without

accreditation to be assessed to support working towards timely national standards

The governance in The State Hospital for California for social work was very different to Australia with a process for licensed Clinical Social Workers The accreditation process results in different levels of social work with rigorous supervision requirements training and accountability for a social worker to proceed to the next level


30 9042018 435 PM

8 Acknowledgement To the family members who remain anonymous for the sake of their loved ones in forensic hospitals You have taught me so much about the mental health care system and the importance of support for families and for never ever giving up hope no matter what

To the many people who work in forensic hospitals in Australia and around the world who supported me with my trip when I did not think it was possible while acting as a Senior Manager To those who provided hospitality while I was away and pointed me in the right direction to avoid getting lost Finally for the generosity and kindness of those who helped me with the report when I returned including those who work at the Winston Churchill Memorial Trust I can never thank you enough and I definitely could not have done this without you

To my own immediate and extended family for giving me so much joy in this life Particularly my parents who role modelled the capacity to give so much to so many words will never express the amount of gratitude I have for being your daughter To my husband who is a truly wonderful man with exemplary character and inspires me to be a better person thank you for always being by my side

Lastly to Sir Winston Churchillrsquos wife Clementine If you were alive my hope is the fruit of this work in the future would have made you proud of the legacy we have because of the perseverance and patience you showed in being married to Winston who struggled with the lsquoblack dogrsquo of mental illness

Mount Joy prison in Dublin which has recently started a trial of Social Work in prisons

2016 to support people with mental illness transitioning back into the community


31 9042018 435 PM

9 References

Australian Bureau of Statistics (2011) 12340 - Australian and New Zealand Standard Offence Classification (ANZSOC) 2011 httpwwwabsgovauausstatsabsnsfmf12340

Brown H C (2002) Counselling in Social Work Themes Issues and Critical Debates Eds R Adams L Dominelli amp M Payne Palgrave Houndsmill Basingtoke in Flaskas C (2007) lsquoSystemic and psychoanalytic ideas Using knowledges in social workrsquo Journal of Social Work Practice 21 (2) 131-147

Davies A L Mallows R Easton A Morrey and F Wood (2014) lsquoA Survey of the provision of family therapy in medium secure units in Wales and Englandrsquo The Journal of Forensic Psychiatry and Psychology Vol 25 (5) 520-534

Encyclopaedia of the Nations (2018) httpwwwnationsencyclopediacomUnited-NationsSocial-and-Humanitarian-Assistance-THE-FAMILY-SOCIETY-S-BUILDING-BLOCKhtml Downloaded 18318

Fairly N (2007) Central Regional Forensic Mental Health Services Draft 5 year Development Plan 2007 - 2012 New Zealand Ministry of Health Capital and Coast District Health Board

Flaskas C (2010) lsquoFrameworks for Practice in the Systemic Field Part 1 ndash Continuities and transitions in family therapy knowledgersquo Australian and New Zealand Journal of Family Therapy 31(3) 232-247

Gibney P (2003) Context The Pragmatics of Therapeutic Practice Melbourne Psychoz Publications

Govier T (2002) Forgiveness and Revenge Routledge London

Green M (2016) Workers perceptions of therapeutic interventions with families of patients in a high secure forensic hospital Research Proposal Masters Social Work UNSW

Gunn J (2018) Website Accessed 1218 httpwwwjohngunncoukbiography4586292175

Herman J (1992) Trauma and Recovery From Domestic Abuse to Political Terror London Rivers Oram Press

Lewis (1999) Review of Social Work Service in the High Security Hospitals Department of Health UK

MacInnes D (2000) lsquoInterventions in forensic psychiatry The caregiverrsquos perspectiversquo British Journal of Nursing Vol 9 992-998

National Organisation of Forensic Social Work NOFSW downloaded 11 April 2018 httpnofsworg


32 9042018 435 PM

New South Wales Courts Definition ldquoNot Guilty due to Mental Illnessrdquo (NGMI) httpsnswcourtscomauarticlesthe-mental-illness-defence-in-criminal-trials Downloaded 18318

New South Wales Mental Health Mental Health Act (2007)

New South Wales Mental Health (Forensic Provisions) Act (1990)

Parkinson P (2011) For Kids Sake Repairing the Social Environment for Australian Children and Young People Sydney Law School University of Sydney Research Paper No 1195 127 Pages 3 Dec 2011

Poon W C Joubert L Harvey C (2013) Experiences of Chinese Migrants Caring for Family Members with Schizophrenia in Australia Social Work in Health Care 52 2-3 144-165

Riordan D (2016) Forensic Psychotherapy Australasian Psychiatry The Royal Australian and New Zealand College of Psychiatry Volume 25 issue 3 page(s) 227-229

Reamer F (2008) Social Work and Criminal Justice Journal of Religion amp Spirituality in Social Work Social Thought 213-231

Sinclair J A walking Shadow The remarkable double life of Edward Oxford The Museum of the Mind National Health Services UK

Torrey F (2010) More Mentally Ill Persons Are in Jails and Prisons than Hospitals A Survey of the States Stanley Medical Research Institute and Treatment Advocacy Centre Presentation for and National Sheriffs Association

White M (2007) Maps of Narrative Practice WW Norton amp Company Ltd London

White M (1995) Re-Authoring Lives Interviews and Essays Dulwich Centre Publications Adelaide

Winters A (2017) Solitary Confinement Past Present and Future National Organisation Forensic Social Work (NOFSW) Presentation July Omni Parker Hotel Boston

World Health Organisation (2018) Definition Social Determinants wwwwhointsocial_determinantssdh_definitionen Downloaded 18318


33 9042018 435 PM

10 Churchill Fellowship Summary of Places and People 1 New Zealand

Hillmorton Hospital Christchurch

Diane Davis Senior Clinical Social Worker Gabby Buchanan Clinical Lead Occupational Therapy Forensic Psychiatric Service Christchurch New Zealand

Harry Bennet Centre Hamilton

Dr Rees Tapsell Clinical Director Dr Derek Wright Executive Director Mental Health Services Kylie Balzer Operations Manager Midland Regional Forensic Psychiatric Service Hamilton Henry Rongomau Bennett Centre Waikato District Health Board

Mason Clinic Auckland

Noeline Te Pania Consumer and Family Advisor Regional Forensic Psychiatry Services Auckland

2 USA

Atascadero California

Stephen Sisk-Provencio (LCSW) Chief of Social Work Service Department of State Hospitals California

Ackerman Institute New York

Lois Braverman President and CEO Ackerman Institute for the Family New York

Conference Boston Viola Vaughan-Eden PhD MJ LCSW Board and President National Organisation of Forensic Social Work

Conference Boston Assistant Professor Ali Winters DSW LCSW Department of Social Work Tennessee

3 Canada

Forensic Psychiatric Hospital Vancouver

Professor Johann Brinks Director Clinical Psychiatry Peter Parnell Clinical Services Manager Lynda Bond Director Quality and Safety British Columbia Mental Health and Addiction Services Canada

Forensic Centre Alberta

Professor Sergio Santana Psychiatrist Southern Alberta Forensic Psychiatry Centre Canada

Calgary Family Therapy Centre

Professor Karl Tomm Professor of Psychiatry Calgary Family Therapy Centre Alberta Calgary

Parliament House Ottawa

Senator Kim Pate Non-affiliated (Independent Senators Group) Ontario

Centre for Addiction and Mental Health Ontario

Professor Alexander (Sandy) Simpson Centre for Addiction and Mental Health Toronto


34 9042018 435 PM

4 UK

Bethlem Hospital London

Colin Gale Curator Bethlem Museum of the Mind Bethlem Royal Hospital Kent

Broadmoor Hospital

Daniel Anderson Head of Social Work David Cochrane Head of Forensic Social Work Broadmoor Hospital Crowthorne Berkshire

Oxleas Foundation Trust Kent

Dr Maeve Malley - Family Therapist Consultant Systemic Psychotherapist Adult Mental Health London

Bracton Centre Hackney

Kimberly Shamku Psychologist John Howard Centre Hackney London

West London Mental Health NHS Trust

Jo Bownes Social Worker and Family Therapist WLFS Trust Headquarters Southall London

Family amp Couple Therapy Clinic London

Annie Turner Head of Family Therapy Courses Director The Prudence Skynner London

Springfield Hospital London

Kate Campbell Senior Social Worker Springfield University Hospital London

Kings College London Professor Jill Manthorpe Head Social Care Workforce Research Kings College London Strand Campus London

Whitehall

Lyn Romeo Chief Social worker for Adults Isabelle Trowler Chief Social Worker for Children and Families Department of Health Whitehall London

London Dr David Jones Director People Need People Previous President International Federation of Social Work Chair British Association of Social Work

Rampton Hospital Retford

Lynne Corcoran Head of Forensic Social Care Lynn Johnson Social Work Manager for Mental Health Lorna Breckell Family Support Manager Retford Nottinghamshire

Ashworth Hospital Liverpool

Amanda McBride Senior Forensic Social Worker amp Carer Lead Robert Mclean Head of Forensic Social Care Secure Division Parkbourn Maghull Liverpool Merseyside

5 Scotland The State Hospital Glasgow

Sandie Dickson Involvement and Equality Lead The State Hospitals Board for Scotland Carstairs Lanarkshire

6 Ireland Central Mental Hospital Dublin

Professor Harry Kennedy Clinical Director Pauline Gill Acting Service Director Donal OrsquoMalley Head of Social Work National Forensic Mental Health Service Dundrum Rd Dublin Ireland

Irish Prison Service Dublin

Aisling Flanagan Senior Social Worker Mountjoy Prison Dublin

Key words

Executive summary

Introduction

1 What is forensic mental health


3 Institutional responses to mental illness

4 Contemporary forensic mental health

a Physical environment

b Safety and Security

5 Social Work in a forensic mental health

a The social work role

b Forensic social work

c Therapeutic Interventions



f Stages of Family Therapy practice

g Secondary and Tertiary Victims and Perpetrators

h Family and Carer support group

6 Summary

7 Recommendations

a Clinicians

b Organisations

c Australian Association of Social Work

d Universities

e Commonwealth and State Government in the Australian context

8 Acknowledgement

9 References

10 Churchill Fellowship Summary of Places and People


2 9042018 435 PM

Table of Contents Key words 2

Executive summary 3

Introduction 4

1 What is forensic mental health 6

2 The evolution of forensic mental health 7

3 Institutional responses to mental illness 9

4 Contemporary forensic mental health 11

a Physical environment 11

b Safety and Security 13

5 Social Work in a forensic mental health 15

a The social work role 15

b Forensic social work 15

c Therapeutic Interventions 16

d International best practice in Family Therapy 18

e Family therapy and restorative justice 22

f Stages of Family Therapy practice 23

g Secondary and Tertiary Victims and Perpetrators 23

h Family and Carer support group 25

6 Summary 26

7 Recommendations 27

a Clinicians 27

b Organisations 27

c Australian Association of Social Work 28

d Universities 28

e Commonwealth and State Government in the Australian context 29

8 Acknowledgement 30

9 References 31

10 Churchill Fellowship Summary of Places and People 33

Key words Forensic Social Work Therapeutic Families and Carers Mental Health Family Therapy


3 9042018 435 PM






4 9042018 435 PM






5 9042018 435 PM








6 9042018 435 PM





7 9042018 435 PM






8





9





10 9042018 435 PM






11













12






13





14 9042018 435 PM





15 9042018 435 PM






16 9042018 435 PM





17






18 9042018 435 PM







19 9042018 435 PM






20





21 9042018 435 PM






22






23 9042018 435 PM









24 9042018 435 PM










Index event

Family amp Carers

Community



25 9042018 435 PM




26 9042018 435 PM




27 9042018 435 PM




workers












28 9042018 435 PM
















29 9042018 435 PM









30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



3 9042018 435 PM






4 9042018 435 PM






5 9042018 435 PM








6 9042018 435 PM





7 9042018 435 PM






8





9





10 9042018 435 PM






11













12






13





14 9042018 435 PM





15 9042018 435 PM






16 9042018 435 PM





17






18 9042018 435 PM







19 9042018 435 PM






20





21 9042018 435 PM






22






23 9042018 435 PM









24 9042018 435 PM










Index event

Family amp Carers

Community



25 9042018 435 PM




26 9042018 435 PM




27 9042018 435 PM




workers












28 9042018 435 PM
















29 9042018 435 PM









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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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workers












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9 References
















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33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



8





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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



9





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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



10 9042018 435 PM






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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



17






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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



18 9042018 435 PM







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9 References
















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33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



19 9042018 435 PM






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Index event

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workers












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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



20





21 9042018 435 PM






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Index event

Family amp Carers

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workers












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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



21 9042018 435 PM






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23 9042018 435 PM









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Index event

Family amp Carers

Community



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workers












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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



22






23 9042018 435 PM









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Index event

Family amp Carers

Community



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workers












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9 References
















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2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



23 9042018 435 PM









24 9042018 435 PM










Index event

Family amp Carers

Community



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workers












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9 References
















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33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



24 9042018 435 PM










Index event

Family amp Carers

Community



25 9042018 435 PM




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workers












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30 9042018 435 PM








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9 References
















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33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



25 9042018 435 PM




26 9042018 435 PM




27 9042018 435 PM




workers












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29 9042018 435 PM









30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



26 9042018 435 PM




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workers












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30 9042018 435 PM








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9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



27 9042018 435 PM




workers












28 9042018 435 PM
















29 9042018 435 PM









30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



28 9042018 435 PM
















29 9042018 435 PM









30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



29 9042018 435 PM









30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



30 9042018 435 PM








31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



31 9042018 435 PM

9 References
















32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



32 9042018 435 PM















33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



33 9042018 435 PM








2 USA







3 Canada












34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References



34 9042018 435 PM

4 UK



Broadmoor Hospital













Whitehall













Key words

Executive summary

Introduction
















6 Summary

7 Recommendations

a Clinicians

b Organisations


d Universities


8 Acknowledgement

9 References


“to study the benefits of engaging families and carers of ... · class social work service to...

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