Extreme Nursing: Forensic Adolescent Mental Health Nursing in Australia

Journal of Child and Adolescent Psychiatric Nursing, Aug 2006 by Cashin, Andrew

Whether forensic psychiatric nursing is a subspecialty of psychiatric nursing or simply the practice of psychiatric nursing in a special context remains an open debate. The word forensic pertains to legal proceedings (Weller, 2005). When forensics is applied in the context of health care it refers specifically to that area of law applied in the criminal justice system. The people whom forensic psychiatric nurses care for have been charged with an offense under criminal law and are thus ensconced in the criminal justice system and may be pre- or post-sentencing.

The nurse working in forensic psychiatric nursing in a juvenile setting is working with a cohort of patients that are characterized by higher degrees of social dislocation, abuse, mental illness, school failure, chronic physical health problems, and poverty than the general population (Department of Juvenile Justice, 2003). Related to these factors, these patients have often had poor access to services, compounding the problems of lack of illness identification and treatment (Levy, 2002, 2005). For those who have accessed services, "there is a downward drift of violence and illness severity from other settings leaving forensic facilities with the most disturbed and intractably violent patients" (Carney & Morrison, 2002, p. 11 ). A "hot potato" service approach of passing on "difficult to manage" and "resource-costly" children and adolescents results in their ending up in the forensic system (Shelton, 2003). To use the common vernacular, forensic psychiatric nursing is extreme nursing. Despite psychiatrists calling for prisons and detention facilities to conduct research, as early as the 1930s, little systematic research has been conducted that guides forensic practice (Rothman, 2002) in either psychiatry or psychiatric nursing (Norman & Parrish, 2002).

The incidence of psychiatric illness and mental ill health in the population of those under the jurisdiction of the criminal justice system is staggering (Butler & Allnutt, 2003). The data support the claim that prisons in particular have become some of the largest mental health institutions throughout the world (Bell, 2005). In New South Wales (NSW), Australia, it was found that the incidence of mental illness in adult facilities was extremely high and declined as prisoners got older, with anxiety, affective disorders, and psychosis as the most prevalent in that order (Butler & Allnutt). The incidence of mental illness in juvenile facilities, those settings housing the youngest of offenders, is huge. In NSW, it was reported that 88% of young people incarcerated had at least mild symptoms consistent with a clinical disorder, the most common of which were substance use disorder, conduct disorder, and adjustment disorder. Comorbidities were common in this population (Department of Juvenile Justice, 2003).

In NSW, a decision was reached after some deliberation to employ the term justice health in the place of the previous title corrections health for the health service in which forensic psychiatric nurses are employed. This decision was based on a hope that the new title would encompass the broader nature of the role than delivery of care in prisons and detention centers only, and thus contribute to a more accurate understanding of forensic care. Forensic psychiatric nurses work in the community, courts, prisons, forensic hospitals or wards, and detention centers.

Prison as a punishment, or criminal sanction itself, is an American invention that has been exported to the world (Morris, 1974). Punishment in society has developed to meet retributive, disabling, and deterrent ends. Since the inception of prison as punishment in around 1790, as opposed to a place of detainment awaiting punishment or containment whilst working off debt, the United States and Australia have progressively locked up proportionately increasing numbers of their citizens. The United States, perhaps rightly as leader and inventor of prison as a punishment, imprisons a higher percentage of its citizens than any other developed country (Bell, 2005). Forensics is a growth area with approximately a 7% per annum increase in the NSW prisoner population alone. This increase in the number of citizens who come under the jurisdiction of the criminal justice system is often justified and promoted by politicians as, "getting tough on crime." The rhetoric related to the goal of imprisonment has swung cyclically between traditional retribution and deterrence to the more humanistic rehabilitation. Programs have been put in place, run for a while, and abolished, only to be replaced by those rationalized under the current theme of intent of imprisonment, which is shaped by the current social policy, without a systematic evaluation of success of any program in achieving the stated need (Rothman, 2002). With regard to adolescents, the few evaluations of reformative success that have been conducted have reflected high rates of recidivism and a trajectory leading to incarceration as an adult. This was true in Sheldon and Eleanor Glueck's study of 1,000 boys in 1934 (Rothman). It remains true in contemporary times (Chen, Matruglio, Weatherburn, & Hua, 2005). The deterrent function of imprisonment or criminal sanctions has been shaped by political speak such as "truth in sentencing," with a net effect of more people being incarcerated for longer periods.