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Psych CASC / OSCEForensic psychiatry — therapeutic security

Psych CASC / OSCE · Forensic psychiatry — therapeutic security

Explain therapeutic security and placement to a general adult consultant — CASC communication station

MRCPsych/FRANZCP-style CASC: communicate secure care levels, least restrictive matching, and interim risk management to a non-forensic consultant colleague.

communication2 min readVerification in progress

Target exams

FRANZCPMRCPsychABPNMD-DNB
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Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
A general adult consultant is frustrated that a patient with schizophrenia and a serious assault history has waited weeks for a forensic bed. They demand 'just put him in high secure' and threaten to keep him secluded on an acute ward 'until forensic sorts it'. You must explain therapeutic security, why security level is matched not maximised, what medium versus high principles mean, the role of relational and procedural security on the acute ward while waiting, least restrictive practice, and how step-down works later — calmly, without inventing statute section numbers.

Station brief

Format. Communication station, approximately 7–10 minutes after reading time. You are the forensic psychiatry registrar speaking with a general adult consultant (examiner role-player). [1]

Candidate instructions. Validate safety concerns. Explain therapeutic security (physical, procedural, relational). Clarify that high secure is for grave and immediate risk, not a default waiting-room. Agree interim management: observation, medication optimisation, least-restrictive alternatives to indefinite seclusion, and structured referral information for correct security matching. Mention that once in secure care, the goal is treatment and step-down, not permanent high containment. No invented statute numbers. Check understanding. [2][3][4]

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References6ShowHide
  1. [1]Flynn G, O'Neill C, McInerney C, et al. The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study BMC Psychiatry, 2011.PMID 21410967
  2. [2]Chester V, Alexander RT, Morgan W. Measuring relational security in forensic mental health services BJPsych Bull, 2017.PMID 29234515
  3. [3]Kennedy HG, Mullaney R, McKenna P, et al. A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders) BMC Psychiatry, 2020.PMID 33097036
  4. [4]Jewell M, Pillai K, Cavney J, et al. Examining the need for a high level of therapeutic security at a regional forensic mental health service in Aotearoa New Zealand Psychiatr Psychol Law, 2024.PMID 38628253
  5. [5]Fazel S, Fimińska Z, Cocks C, et al. Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis Br J Psychiatry, 2016.PMID 26729842
  6. [6]Davoren M, O'Dwyer S, Abidin Z, et al. Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20 BMC Psychiatry, 2012.PMID 22794187
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