I visited Long Bay Hospital in Matraville, Sydney Essay Example

leaving only two seclusion rooms available. The duty psychiatrist even mentioned the possibility of a waiting list further highlighting the stress and demands on the hospital.

Long Bay Hospital has a distinct prison culture and lacks the secure atmosphere expected of a psychiatric hospital. The hospital grounds offer clear views of guard towers and security measures that resemble those of a prison rather than a psychiatric unit. This is not surprising, considering the facility's location. Additionally, the interior of the hospital is unwelcoming.

The patients' rooms are more reminiscent of cells than bedrooms as they have heavy metal doors that lock externally and basic facilities within. The close-observation rooms, where patients who are at risk of suicide or deliberate self-harm are placed, offer little privacy. These rooms are under twenty-four-hour close-circuit video monitoring and are almost stark with no television, radio, books, magazines, or any other form of daytime occupation except for a pack of playing cards for the inmate. At the time of my visit, Ward D is mostly serving patients who are acutely psychotic or recovering from acute psychosis. Of the six patients seen in the ward round/case conference, all exhibited symptoms of schizophrenia. Substance abuse was a common dual diagnosis among several patients.

During the visit, it was observed that one patient had comorbid paranoid and antisocial personality disorders. The psychiatric hospital caters to relatively young patients, typically in their 20's and 30's. In contrast, community facilities admit a considerable number of middle-aged to elderly patients with chronic/refractory mental illness. However, all patients encountered during the visit had notable psychosocial issues and had experienced some form of family dysfunction during their childhood,

from family breakdown to abuse.

All residents in the visited ward had limited education and scant employment histories, and were repeat offenders with a variety of criminal records ranging from minor misdemeanors to violent crimes, such as aggravated assault and armed robbery. Ward C also has a mixture of patients, but tends to be more subacute. Ward A is primarily for forensic patients including those who are detained while their fitness to stand trial is being determined, those who are found unfit to be tried, those who are not guilty by reason of insanity, and prisoners transferred to the hospital due to mental illness according to legislation [1].

During my visit, I noticed that the hospital had five doctors and around six nurses were present in ward D while there were probably equal numbers in the other two wards. The primary responsibility of this medical team and their support staff is to provide daily patient care and carry out court-ordered psychiatric evaluations. Additionally, six corrective services officers are allocated to ward D. Although they are trained in security, physical fitness, conflict resolution and laws, they lack knowledge related to psychiatric patients.Although there may be younger officers who hold more liberal views, the majority of senior staff in the hospital's psychiatric unit have been affected by the hostile occupation culture in which they were living. This is evident in their attitudes towards patients. To learn more about security measures, click on the link to visit which one of these does not pose a risk to security at

a government facility. Many of the 90 patients in this unit have come from various prisons throughout New South Wales including Silverwater and Grafton. Generally, when admitted for an episode of psychosis, patients have been assessed by either a duty psychiatrist or a crisis team at their "home" prison before being transferred to Long Bay Hospital. This same process is found in communities where a sufferer may be referred to an inpatient facility by their GP, case manager or carer for urgent intervention.
Upon entry at Long Bay Hospital, prisoners receive the same assessment and treatment as any other psychiatric patient.The ability to conduct a thorough assessment may be limited by factors such as time constraints, a shortage of qualified staff, and security requirements.

Due to their circumstances, patients in forensic psychiatric hospitals may exhibit uncooperative behavior along with guarded and mistrustful attitudes. They may primarily concentrate on the impact of their legal situation on their symptoms, treatment, and outcome, rather than the illness itself. During a visit, a patient repeatedly referred to his parole likelihood regarding compliance with treatment. Obtaining supporting documents or conducting interviews with relevant third parties can be challenging while trying to conduct court-ordered psychiatric remand assessments for prisoners who possess either little or scattered medical backgrounds. Additionally, security implications may impede arrangements for special investigations such as neurological imaging [2].

Long Bay Hospital has admission criteria that resemble those of a typical psychiatric hospital, with most patients having some form of psychosis like schizophrenia or mania. Patients can also be admitted for major depression, suicidal ideation, and repeated self-injury. Previously, patients may have engaged in deliberate self-harm as a means to temporarily escape

their confinement.

The facility primarily manages acute and subacute cases with pharmacotherapy due to a rising number of mentally ill inmates and scarce resources. Patients who lack awareness of their psychotic symptoms and reject treatment may be required to take medication administered by the Mental Health Act, similar to those in the community. The drugs prescribed are analogous to those used in a general psychiatric hospital.

Long Bay Hospital has a higher proportion of patients who are on depot drugs due to their agitated behavior and noncompliance issues. Regular reviews and consultations are conducted to monitor illness progression and decide on the possibility of discharge. Discharge follows the same principles for every patient with chronic mental illness- their capacity to function outside the hospital environment. After discharge, most psychiatric patients return to their respective prisons, where they are followed up by the resident psychiatric clinic. Some patients are transferred to the Kestrel Unit at Morriset Hospital, a maximum-security unit designed for forensic patients. While others are released from remand or at the expiration of their sentence [3].

A Clinical Vignette

Daniel, a 30-year-old Caucasian man with chronic schizophrenia causing auditory hallucinations identified as the "voice of God", was transferred from Junee prison to Long Bay Hospital due to an acute psychotic episode leading to paranoid delusions. While it is uncertain whether he committed two counts of aggravated (sexual) assault against two young girls during one of these episodes, Daniel believed that his actions were justified by the "voice of God". As a result, he was convicted and sentenced to four years in prison with a minimum non-parole period of two years.

At present, Daniel's total sentence has 12 months left.

Risperidone is his primary management medication in Long Bay Hospital, and it has significantly improved his symptoms. Nonetheless, his religious delusions persist despite medication adherence and impaired insight. The interview revealed Daniel's typical blunted affect as a patient with schizophrenia.

Despite being somewhat reserved, the individual was open to discussing their legal troubles rather than their past symptoms. They specifically spoke about how they were denied parole by the Parole Board for not participating in a Relapse Prevention program, which is viewed as an indication of rehabilitation. As a result, their sentence now surpasses the non-parole period. The discussion also included information about the individual's release, with their treating psychiatrist determining that their current mental state is at its optimal level. The psychiatrist believes that they are prepared to return to Junee prison and receive follow-up care from the facility's psychiatric outpatient clinic.

Despite having no fixed abode and little social support, Daniel's continuity of care will become difficult after his release in a year. Relevant issues that were brought up from this clinical case and discussion include the treatment and rehabilitation of mentally ill violent offenders. The NSW Department of Corrective Services employs over 75 psychologists who are responsible for providing psychological rehabilitation to inmates through Relapse Prevention and other psychotherapies. Relapse Prevention is a type of cognitive behavioral therapy that aims to assist the offender in recognizing the typical events that lead to aggression and developing more adaptive methods to deal with them, which can then help to avoid aggression. This approach diverges from traditional psychotherapy that focuses on modifying aggressive behavior itself [4].

Although it may be successful for offenders with a good comprehension

of their actions, this approach is unlikely to help inmates with chronic delusions and limited insight, including Daniel. These patients are unlikely to be motivated to change unless it is to use the program to convince the Parole Board that they have addressed the factors that led to their offense. More importantly, managing violent and mentally ill inmates should concentrate on discovering the symptomatology behind their aggression, which is not a single treatable symptom but rather a heterogeneous act. Therefore, for individuals such as Daniel, whose criminal violence is closely linked to his psychosis, it is more effective to focus on treating the underlying causative factor, which in his case is his hallucinations, rather than his aggressive behavior. Continuity of psychiatric care can be a significant issue for people like Daniel who have no stable social base before entering prison.

Although he may be monitored in Junee prison's psychiatric clinic, this monitoring is unlikely to be sustained after his release. Currently, New South Wales lacks a coordinated plan to ensure the continuity of care for forensic psychiatric patients reintegrated into the community. While the staff at Long Bay Hospital endeavor to connect discharged patients with community mental health services, difficulties arise for patients without prior support. Some see ex-prisoners with mental illness as the responsibility of the corrective services system, which is distinct from the community, hampering effective service coordination [6]. Moreover, numerous service providers, especially general practitioners, are hesitant to accept ex-prisoners as clients. These issues are troubling because without sufficient support to guarantee medication adherence, patients are at significant risk of relapse, psychosis, and re-offence [1, 6].

Effective models for psychiatric care

have been adopted overseas, such as the UK's Care Program Approach, the US National Association of Social Workers' continuity of care plan, and a similar strategy recommended by the Canadian Mental Health Association [6,7,8]. These models involve coordinated efforts between prison medical systems, community mental health providers, and probation services to connect clients with post-release treatment and support. Planning for this transition begins while the patient is still in the prison system to ensure a smooth process, with the prison medical service providing some post-release care until the designated community service takes full responsibility [6,7].

In addition to problems with continuity of care, the New South Wales forensic psychiatry service requires changes in several areas. One major issue is the prison-like environment at Long Bay Hospital, which impedes the development of a therapeutic relationship and consequently quality treatment and rehabilitation. This issue arises due to conflicting attitudes of custodial staff and healthcare professionals. While security is the primary concern for custodial staff, healthcare professionals aim to improve the health of patients.

Furthermore, complying with prison regulations in the interest of security can lead to inefficiencies in accessing patients. As an example, on the day of my visit, the inmates had to be "locked down" for an additional hour due to the absence of custodial staff attending a meeting. Consequently, the psychiatrist responsible for treating them was unable to conduct interviews. In 1997, NSW Corrections Health Services engaged Professor Robert Bluglass from the UK to undertake a Review of Forensic Mental Health Services NSW.

The report recommended creating a stand-alone psychiatric hospital with maximum security. The hospital should have a therapeutic setting like those in South Australia, Queensland, and

Victoria [1]. This type of hospital would provide a more effective therapeutic environment with better access to patients and treatment in a less hostile atmosphere. Psychiatric patients require properly trained staff rather than corrective service custodial officers. Additionally, building a new hospital would ease the burden on the existing Long Bay Hospital, which only has 30 medical beds to serve the entire prison.

The Bluglass Report highlighted the need for a multidisciplinary program for patients in Long Bay Hospital, incorporating non-pharmacological approaches like occupational therapy [1]. However, despite this recommendation, it seems little has been done to implement such a program. Interviews with staff members and personal observations suggest that, aside from a limited diversional therapy program featuring art and cooking activities, patients lack occupation opportunities and appear dispirited. This is unfortunate because, as seen in Mulawa women's prison [1], occupation opportunities could improve motivation and mood. Despite ongoing development and increased funding, there is still much room for improvement in Long Bay Hospital's service provision. Corrective Health Services have formed a working group to assess recommendations in the Bluglass Report, but the most important proposal- establishing a stand-alone maximum-security forensic psychiatric hospital- has yet to be considered. It remains to be seen whether this proposal will become a reality based on fiscal decisions made by the New South Wales government.