FORENSIC MENTAL HEALTH
“The first,” he said, “is the architecture and design elements – for instance having good sightlines – so you can observe that everybody is well, you’re controlling entrance and egress; very straightforward things universal in any such building. The second is the most important – relational therapeutic security, i.e. the staff / patient ratio. In an intensive care area or acute ward, there’ll be a lot of staff for each patient, while in a ‘rehab’ pre- discharge area, there’ll be progressively less. The third element is procedural, and again, that’s about doing regular risk assessments, actively managing stay length, triaging who comes in, and ensuring that patients go to the right level of care, as well as managing the risks, taking therapeutic risks, and knowing when it’s right to return somebody to the community. That was the system I introduced in North London, and it worked in Dundrum. While I wasn’t the first to name the elements, turning them into something operational was useful, because it linked that to patient characteristics, which in turn became ways of communicating, explaining decisions – for instance, to judges, because everything we do is reviewed legally, to protect people’s rights.” This activity, he explained, led on to the development of the DUNDRUM (Dangerousness, Understanding, Recovery and Urgency Manual) Toolkit – ‘a way of measuring need for therapeutic security, and knowing when people have responded to treatment in such a way that they are no longer a danger to themselves and others’.
Scientific validation Prof. Kennedy said the ‘vital thing’ about the Toolkit was that it is validated scientifically. He explained: “We are able to show that it correctly relates to, and improves, outcomes.” Now used in both Ireland and the UK, it has been translated into French, Dutch, Italian, and Danish.” It was developed against the backdrop of a change in legislation. He elaborated: “In Ireland we were still operating on Acts dating from the 19th century, and in 2010, had a complete legislative reform.” One of the upshots was the establishment of Mental Health Review Boards to ensure that people’s rights were being respected, and detentions independently reviewed. The Professor said: “We knew this could be very unstructured, time-consuming, and unreliable, from our experience in other jurisdictions, and wanted to make
The National Forensic Mental Health Service Hospital in Portrane sits on about 20 acres on the top of a low hill, and is completely surrounded by 15-metre high trees.
it more scientific and clinical, which is why the Toolkit was developed. It’s a handbook, and what’s called ‘a structured professional judgement instrument’, or ‘set of instruments’, and it works within a model of care.”
Toolkit’s four elements Prof. Kennedy continued: “It has four elements: it sets out what the service’s goals are – what the pathways through care are: How do you come in?; How do you progress? When are you ready to step back into the community? It also sets out how treatments are resourced and delivered.” The first three chapters set out ‘Goals’, ‘Pathways and Processes’, ‘Treatment’ and then the fourth – ‘the most important element – Evaluation’. The Professor said: “Continuously evaluating is essential.” Professor Kennedy reiterated that he
served as Executive Clinical director of Ireland’s National Forensic Mental Health Service from 2002 until he formally retired in late 2022. He said: “Throughout my career as a psychiatrist, I’ve been a Clinical director, a clinician who treats patients, and an academic – a researcher, and a teacher – so I can now spend more time on research and teaching. That type of combined clinical and academic leadership was very common for my generation, and the previous one. Forensic hospitals, particularly, were usually led by an academically active senior clinician. “Nowadays, clinical management is so
Throughout my career as a psychiatrist, I’ve been a Clinical director, a clinician who treats patients, and an academic – a researcher, and a teacher – so I can now spend more time on research and teaching. That type of combined clinical and academic leadership was very common for my generation, and the previous one. Forensic hospitals, particularly, were usually led by an academically active senior clinician
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time-consuming it’s very difficult to sustain a decent academic career, and people who are good academically generally don’t want the burdens of modern management – which are increasingly remote from good clinical practice. So those roles tend to be split, and most of my counterparts are being succeeded by two people – a clinical manager, and a clinical academic.” Prof. Kennedy is a Visiting Professor
at the University of Bari Aldo Moro in Italy, where his colleagues and friends are evaluating ‘the radical change in how forensic hospital care is delivered in Italy’. He elaborated: “Most people know about the Trieste reforms, when by law, the Italian state closed all the country’s psychiatric hospitals from 1978 onwards, with a view to replacing them with a network of services fully embedded in the community, highly accessible, and with a low access threshold. People often forget that at the time they didn’t close their forensic hospitals, but in 2015, by law, they closed the legacy such hospitals called OPGs (Ospedale Psichiatrico Giudiziario), and opened different, smaller units called REMS (Residenze per l’esecuzione delle misure di sicurezza). The latter are limited to 20 beds each. The degree of success of the move is currently being evaluated.”
Plans for the new hospital Returning to his work in Ireland, I asked Prof. Kennedy to say a little more about when plans for the new National Forensic Mental Health Service Hospital first emerged, and their protracted development. He said: “Following the 1998 report of the Committee for the Prevention of Torture inspection, the need for a modern, fit-for-purpose facility was agreed. I returned to Ireland in early 2000 on the promise that a new hospital would be opened by 2005. Unfortunately, we spent the first 13 years trying to agree where it would be built. We wanted to rebuild on the very central Dundrum campus. If you walked out the gate you had all the city’s amenities on
NOVEMBER 2023 | THE NETWORK
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