Privilege, power and trust

What led you to becoming a forensic psychiatrist?

I was a lawyer working in commercial litigation – young and ambitious, a senior associate aiming for partnership. I decided to start a family, but was concerned I would not be able to balance family and the long hours of a career in litigation. I was looking for an alternative option that would enable my career to stay somewhat on track whilst I had young children. I thought a medical degree would help me return to law with a strong advantage. I had already done a Masters in Law and university lecturing, but did not want to pursue this further. Besides, lots of lawyers (including me) have a fascination with doctors and medicine. I was quite naïve about medicine and once I started the medical program I realised that it was more than a job but a privileged vocation (and a lot of work). I loved psychiatry, and early on it was obvious to me that forensic psychiatry would be a perfect marriage for my combined degrees.

How did your personal values affect your career choice?

My personal values centre around the belief that we should contribute to society in some meaningful way and that we should strive to do the right thing (whilst acknowledging that this is often complex). In psychiatry, as a doctor, you are in a position of great power and privilege in relation to those who are highly disadvantaged in society. Mental illness impacts on your ability to interpret reality and often impairs your judgment. This results in the need for great trust in those who are responsible for the care and treatment of the mentally ill. Those mentally ill who are unfortunate enough to find themselves before the criminal justice system are even more vulnerable. Their ability to access treatment and navigate the justice system can be highly compromised by their illness. Many mentally ill inmates have committed minor offences such as not having a ticket on a train or public disturbance offences, but are unable to provide an address for bail, for instance, and end up in custody as a result. These people can be extremely vulnerable in the hostile custodial environment and will often not seek out treatment due to their distrust of mental health services. Treating and caring for this highly disadvantaged group can be very rewarding. I believe that being involved in the care and treatment of this group enables me to make a much more significant contribution to society than I could ever do as a lawyer.  In addition, I believe that forensic psychiatry is an area where there are many challenges but that it is important and right that we push through those challenges in an attempt to help and support this disadvantaged group.

What are the most important qualities of a forensic mental health practitioner?

In my view, it is most important for the forensic mental health practitioner to be able to empathise with the person before them in some way, regardless of what that person has done, or how they present. This enables the practitioner to treat the patient as a person not as an offender. In addition, a forensic mental health practitioner must be able to identify and reflect on the emotions (good or bad) that the person engenders in them to ensure those emotions don’t get in the way of the practitioner’s ability to properly assess, treat and care for that person. Finally, the treating forensic mental health practitioner, like all doctors, must be able to keep the patient as the centre of the focus of care, regardless of the other tensions (such as resource or systems issues). In expert report writing, it is most important to stay focussed on your own values and make every effort to maintain an independent honest view. I think these qualities are actually very hard to achieve in practice.

What does your current role involve?

I am employed as a staff specialist in the acute male unit at the high secure forensic hospital and I prepare private expert reports for Court. I have clinical responsibility for forensic patients on that unit. These patients have been found not guilty by reason of mental illness or are unfit for trial. As an expert, I assist the Court by assessing defendants and providing opinions on, for example, the presence of any mental illness, the relationship between their mental disorder and offending conduct and/or recommend treatment/rehabilitation plans. I am also Chair of Medical Staff Council for Justice Health, which is an elected position. The Medical Staff Council reports to the Board of Justice Health on medical matters.

What does a successful day for you look like?

In the hospital setting a good day would be when there are no aggressive incidents on the ward.  However, a successful day might take various forms. It might involve facing a serious incident of aggression and working as a team (including the nursing staff, allied health and medical staff) to achieve a peaceful de-escalation of the situation. I have been involved in numerous situations like this, including a patient who armed himself with sharp pieces of plastic from a broken music player, barricaded himself in his room and threatened to cut his own throat or a staff member’s throat if they entered the room. Working together with the nursing staff we managed to convince him, through a de-escalation process, to surrender the weapons and cooperate with staff without incident. A successful day has also occurred when a patient with treatment-resistant schizophrenia who had a delusional system for 20 years despite treatment was placed on the right medication (after months of encouragement) and the delusional system resolved in three weeks. He developed insight and after years of distrusting mental health expressed much gratitude for the treatment he had received. It can be very satisfying to be part of a team that works effectively together and to have so many great people by your side.

What is the biggest challenge currently facing the delivery of prison healthcare services?

The biggest challenge in the delivery of prison healthcare services is ensuring access to minimum standards of healthcare in a population with substantial severe physical and mental health morbidity who are housed in correctional facilities often in regional or rural areas with little ability to control their environment or communicate with others and often with limited education, poor communication skills and few to advocate for them.