The Conflicting Roles of the Forensic Mental Health Nurse - Essay Example

FORENSICS AND NURSING by Introduction The terms ‘forensic’ and ‘nurse’ could be said to be incompatible in a variety of ways, in that the former has legal connotations whilst the latter is majorly associated with care provision and compassion. When brought together, they form a profession that entails a variety of roles, responsibilities and decision-making processes each of which should be considerate of either aspect of the professional mental health worker. As Aiyegbusi (2012) portends, this is in consideration of the need that the mental health nursing professional should effectively and holistically fulfil both aspects of the profession. To understand the crucial role-play of the forensic mental health nursing professional, it essential to know more about the field under study. This is informed by the fact that this medical fraternity is virtually engaged in constant dual diagnosis as well as subsequent treatment procedural measures (Aiyegbusi, 2012:7). Forensic Mental Health Care: A Review Forensic mental health care as a care service sector is an essential provider of both assessment and subsequent treatment of individuals with varying forms of mental disorders especially those who have been or are potentially a risk to other individuals. Such risk, it should be noted, is mainly linked to the form of mental imbalances displayed; hence, provision of such services at various stations in a given community is required. Due to the present history of criminal offences by individuals considered a risk to themselves as well as others, there is need of the dual diagnosis as part of overall treatment measures (Adshead & Jacob, 2008:9). Such individuals are often at the risk of future offending, thus the essence of treatment provision should be available in hospitals, prisons, courts, police stations/facilities and the larger community setting (Adshead & Jacob, 2008:11). As Bartlett and McGauley (2010) indicate, individuals who can be definitively categorized into this risk-population group are often those people who are involved in an offence in a given jurisdiction’s criminal justice system in one way or another. It is widely accepted that secure hospitals provide the best avenues through which such individuals may receive optimal treatment (Bartlett & McGauley, 2010:32). To be noted however, is the fact that such service provision does not necessarily target those involved in existing criminal justice systems but wholesomely encompasses individuals considered as high risk persons. Individuals who are often referred under such case scenarios are those who cannot be adequately catered for within other prevailing mental health service institutions/ facilities (Bartlett & McGauley, 2010:35). Accordingly, if an individual suffers from any form of mental illness and is further negatively involved with a given jurisdiction’s criminal justice system, he/she can be moved into general health systems present. This is referred to as diversion, which is the movement of affected individuals from such criminal settings and into more conducive environments requisite for their wholesome treatment and recovery. Under the Mental Health Act, the police have the power to arrest and detain individuals in the event they are suspected of having been involved in criminal activities (Bradley, 2009). Adding to this is the fact that the police can also detain individuals, in the event they perceive an individual to be less safe under normal social environments. When under detention for their own safety, as Aiyegbusi & Clarke-Moore (2008) portend, affected individuals can be assisted through state law that necessitates the provision of certain social services. Under such contexts, affected individuals are able to ask for and gain access to forensic physicians and individuals who are mandated to assess and diagnose their mental health and wellbeing (Aiyegbusi & Clarke-Moore, 2008:44). Forensic mental officials thus include doctors, paramedics and nurses all of whom are critical segments of the greater forensic mental health service sector. Under special cases, liaison and diversion schemes are incorporated where the public can be able to find help through the police. The staffing officials present in these services often visit individuals in police stations subsequently assessing the mental health of such ‘detained’ persons (Aiyegbusi & Clarke-Moore, 2008:47). Ayres & Koch (2009) allude to the fact that these officials are mainly concerned with the mental health and wellbeing of such individuals, hence their strife to ensure that concerned parties are able to get the right form of support and can hence ‘divert’ them from ‘normal’ criminal justice systems and into pertinent health care systems (Ayres and Koch, 2009:44). From different research studies undertaken, it is noted that individuals within existing criminal justice systems have considerably higher rates of mental disorders and illnesses compared to populations in the general society, thus the need for the professional forensic mental health nurse (Ayres & Koch, 2009:45). Another important issue is the fact that individuals suffering from mental illnesses and/ or disorders are also more likely to be under detention in terms of imprisonment, sentencing or custody. This is in addition to the fact that they could be victims in varying forms of criminal offences. The term forensic pertains to, or is associated with legal issues with respect to certain aspects of the judicial systems under consideration (Soothill, Rogers & Dolan, 2008:48). Holistically, forensic mental health service provision entails the assessment, diagnosis and eventual treatment of individuals diagnosed with one amongst an array of mental disorders or illnesses. A number of reasons behind continued assessment of the mental state of some offenders and those culpable or alleged of offending exist (Department of Health/NIHME, 2005). These include their state of mind at the period of alleged offence making, their current need for such avenues of treatment and their competency in the making of a plea in court. Mental illness, as a term as portrayed by McMurran, Khalifa and Gibbon (2009) encompasses a variety of illnesses affecting the human mind. This may be in the three-phase categorization, i.e. from mild, to moderate and severe in extreme cases. They could also be categorized mainly into two. Mental illnesses are either psychotic or non-psychotic (McMurran, Khalifa and Gibbon, 2009:56). The former pertains to symptoms, such as a distorted view of reality, hallucinations and delusions. Non-psychosis includes symptoms, such as tension and anxiety, sadness, daily-life stresses. In extreme cases, depression as well as anxiety disorders, i.e. obsessive-compulsive disorders and phobias are frequently displayed by affected individuals ((McMurran, Khalifa & Gibbon, 2009:58). Mental disorders are uniquely different with examples that are inclusive of personality disorders where individuals endure disturbances in the manner in which they interact in society, organic brain disorders where there is damage to brain tissue from diseases as dementia and alcoholism and intellectual disability where individual interact is hampered by problems associated with wholesome brain development. Support through Provision of Forensic Mental Health services Forensic mental health service provision represents a lifeline to individuals categorized under such illnesses, disorders, and especially those unfortunate to be involved in criminal justice systems (National Forensic Nurses Research and Development Group, 2007). Examples of populations targeted include prisoners who need in-patient treatment, individuals accused of crime but considered unfit to competently plead because of exhibited mental impairment and individuals unable to be safely managed within existing mainstream service providers. Others include offenders or those alleged of committing crime but are referred to undergo assessment, those living in society but with a serious form of impairment and those who have offended or are at a greater risk of offending (National Forensic Nurses Research and Development Group, 2008). Other individuals include those who are subsequently not found guilty of committing crime due to their mental state and individuals in prison that require either management of assessment of an existing mental illness or disorder. The referral of such individuals to existing forensic mental health service providers is often done by the police, court systems, prisons, community corrections/ institutions and other mental health and/ or justice services (Department of Health and Home Office, 1992). This is aimed at correctly tackling a socio-economic and health issue that inevitably engages prevailing judicial systems because of the participation of affected individuals in crime and criminal activities. As Tarbuck and Topping-Morris (1999) explain, this is done through different treatment options available for individuals suffering from forensic mental health issues. Treatment options include counselling that involves one-on-one (patient-professional) therapy and/ or group therapy sessions, medication, such as anti-psychotics, anti-depressants and other control medicines essential in mitigating some types of symptoms displayed and rehabilitation that usually involves (public) programs directed towards enabling affected individuals to co-exist safely within society (Tarbuck, & Topping-Morris, 1999:77). This is especially crucial in the support of offenders diagnosed with mental health issues, as some or all their actions could be deemed as infringing on existing public law (Tarbuck, & Topping-Morris, 1999:78). The duality in role application of forensic and nursing competencies pre-empts the need of greater knowledge of existing legal issues vis-à-vis continuous promotion of care and compassion within society. As society is based upon and subsequently entrenched within prevailing legal systems, engaging in crime and/ or criminal activities is often considered unwanted, un-warranted and negatively impactful on society in general. As a result, both preventative and punitive systems are in place set up with the core task of regulating overall crime rates. This is with regard to all manner of criminal activities considered in one way or the other an infringement upon societal values and norms (Reed, 1992). Dual Experience: The Conflicting Role-play of the Forensic Mental Health Nurse Key in understanding the concept behind the different roles of the forensic mental health nurse is through positively harmonizing the dissimilar yet complementary competencies of forensic input and health care provision. Due to the dual nature of the profession, there is constant engagement in connection to courts of law (National Forensic Nurses Research and Development Group, 2005). To be noted, however, is that the field ought not to be constrained as application of the profession in terms of evaluations for legal purposes. Rather, it should be viewed as the application of a human face when dealing with individuals suffering varying mental incapacities where the profession is firmly rooted in enhanced clinical practice (Department of Health, 2003). In a court of law, during judicial processes, the forensic mental health nurse often faces unequal struggles in terms of maintaining his/ her dignity as a medical expert. As Chaloner & Coffey (1999) provide, this is mainly due to the varying forms of overwhelming pressures faced, i.e. fiscal and institutional pressures thereby falling victim to the prosecutors’ tactics (Chaloner & Coffey, 1999:31). Thus, when viewed as being necessarily carried out within judicial court systems, the profession faces increasingly greater chances of vulnerability within such procedural application. Accordingly, having a practice and expertise firmly founded upon a platform of clinical application/ practice away from existing legal arenas may provide a greater element of work independence, and hence a firmer basis professional conduct (Chaloner & Coffey, 1999:33). This is aimed at adequately providing competent advice based on clinical expertise to courts of law with regard to the aspects of the affected individuals’ capacity and competency. Above all, the professional application ought not to be limited only to the assessment and subsequent treatment of offenders deemed as mentally imbalanced. This is because such definitive application delineates an arena of concern, which potentially involves almost all of existing mental health service provision (Department of Health, 2001). It is a known fact that offending behaviour is a common occurrence within society and especially amongst the younger generations; hence, the need for application of the professional to be universal. Informing this is the fact that criminal convictions are usually spread widely across society and more so within the group category of those individuals deemed as suffering from mental imbalances. Accordingly, there is greater need of definitively portraying the boundaries of forensic mental health care provision above issues of offensive behaviour or even the eventual criminal conviction of individuals suffering varying forms of mental incapacities (Durcan, 2008)). However, it should be noted that that such boundary descriptions are in the process of redefinition given the current dynamic nature as well as continued development experienced within forensic mental health services within the Western world (Shuker & Sullivan, 2010:87). In practice, as Singleton, Meltzer & Gatword (1998) aver, affected individuals often gravitate towards forensic service providers especially when the offending nature portrayed or the resultant apprehension created because of their behaviour is deemed as being overwhelming to general mental health service providers (Meltzer & Gatword, 1998:45). This is in terms of confidence and/ tolerance, hence the prevailing situational contexts where referral rates continue escalating because of a variety of reasons. This includes such aspects as increased anxieties concerning the potential of violent behaviour exhibited by specific categories of patients in addition to the culture of blame permeating within the general society (Singleton, Meltzer & Gatword, 1998:47). Under such contexts, professionals often fear being deemed responsible for failure in protecting fellow citizens from fear inducing or in extreme cases, violent behaviour of those who have undergone through their care (Fazel & Danesh, 2002:547). Unfortunately, such a shift to community-based mental health services reliant on general hospital units has inevitably decreased overall confidence in existing facilities and skill-sets requisite in the management of potentially frightening and challenging patients. Compounding all these influences are the prevailing changes within society in general, which tend to continuously decrease public tolerance for both intrusive and difficult behaviour (Ashmore & Shuker, 2013:23). Subsequently, there is an increased demand that professionals, as opposed to family relations and neighbours, ought to control such cases of deviance. This is especially in contexts where such threats and disturbances are viewed as primarily arising from mental imbalances in affected individuals (Adlam et al., 2012). Influencing overall role-play and input of medical practitioners within the forensic mental health service sector are the twin issues of risk assessment and risk management (Dale, Thompson & Woods, 2001:74). As emergent central elements within the larger mental health sector, they are both critical in the long-term viability of community care. The latter regards the central tenet of modern mental health service provision and has subsequently become depended on the alleviation of the general public anxieties (Dale, Thompson & Woods, 2001:74). This is about the perceived danger of individuals deemed to be suffering from mental imbalances. To the professional forensic mental health practitioner, this state of affairs is disheartening given the potential danger of seriously damaging and/ or destroying the substantive progress achieved (Dale, Thompson & Woods, 2001:77). While such misplaced and exaggerated ideals represented through varying public fears may be occasional, they do pose danger on overall effectiveness of service provision. This is founded on their core role of doing everything possible, in order to appropriately care for, and support affected individuals especially those most likely to portray or engage in violent actions (Kettles & Woods, 2006:21). The critical aim is to identify and subsequently manage such risks before their manifestation in violence, crime and criminal activities. The probable emergence of difficult, socially disruptive and aggressive behaviour, which can lead to distress for patients, their relations and the wider society that can be identified in advance. In addition, with proper management, prevention of such emerging conflicts can be adequately tackled and/ or prevented (Kettles & Woods, 2006:23). However, the problem exists in the fact that it is impossible for mental health service providers to adequately prevent all forms of violent acts as exhibited by their patients any more than the general society can be able to comprehensively achieve. In this regard, what remains highly problematic is early identification of those individuals who may eventually/ potentially inflict serious or fatal injuries to the rest of society (Arkowitz et al., 2008). To be noted is that these potential and likely offenders form only a tiny minority of the general society, hence the need for their distinction from normal populations. This aim at adequately tackling the legal issues at hand in consideration of the incapacity of those charged with such offences (National Institute for Health and Clinical Excellence, 2005). The most important factor to consider is that it is essential for the forensic mental health profession to adequately consider all facts presented, during legal proceedings with regard to individuals accused of crime and who are perceived to be psychologically imbalanced. The aim is towards effectively portraying the presence or absence of such mental imbalances vis-à-vis the implications portrayed within criminal judicial systems (Department of Health, 2005). The end-goal is for the forensic mental health expert to adequately portray the presence of imbalances that eventually may prove an individual of being either complicit or capable of engagement in crime or criminal activities. This is informative given the fact that the prevailing campaigns of blame especially of mental health care providers with regard to failing to adequately prevent crimes, i.e. homicide only result in justice not being served (HM Inspectorate of Prisons, 2007). The result of such contexts, as Dickinson & Wright (2008) provide is hinged on the increased utility of defensive and coercive practices that result in only a postponement and superficial tackling of the core issue at hand. The fact that individuals suffering from mental imbalances need to be considered differently from the rest of society is essential, to address the varying nature of consequences to be endured (Dickinson & Wright, 2008:84). In this way, much is gained by way of openly discussing the best possible methods of not only identifying but also managing such potentially aggressive individuals. This is in addition to effectively engaging in programmes that entail the analysis and subsequent learning from the inevitability of such incidences and/ or failures (Dickinson & Wright, 2008:85). In this regard, the professional forensic mental health provider needs to distinguish between normal human functionality and its link to retrogressive social ills from imbalanced human mental status, and the unfortunate occurrence of unacceptable social behaviour. Retrospectively, it is incumbent upon such professionals to also adequately provide sufficient evidence linking offending individuals’ behaviour to mental imbalances in existing judicial processes (Kettles, Woods & Collins, 2002:98). The aim is to considerably prove beyond doubt that such accused individuals either ‘willingly/ knowingly’ committed such actions vis-à-vis their lack of mental capacity in comprehending the consequences of their actions. This is in line with continuously enabling justice to be observed and served on equal measures within society (Drennan & Alred, 2012:25). In conclusion, it is important to acknowledge the fact that risk factors represent considerable statistical associations, which are subject only to provisions that such risk factors precede the ‘predicted/ potential’ outcomes. In actuality, while presented as innocent of both social and cultural assumptions, such associations are often fundamentally influenced by the same assumptions, i.e. history of child abuse or being a male is inevitably linked to predictions of future involvement in dangerous activities or action. In this regard, risk assessments and their subsequent management should be the main concern of existing professionals to the extent that there is initiation of adequate remedial interventions. The aim is to directly or indirectly benefit the individuals assessed and thereby deemed to be unfit to competently represent themselves during court proceedings when charged with an offence. 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