Therapeutic security — placement and step-down (MEQ)

(i) Therapeutic security and three domains. Therapeutic security is the integrated use of security measures to enable safe treatment and rehabilitation of people with mental disorder who pose risk of serious harm — dual clinical and public-protection purpose, not punishment. Three domains: physical/environmental (perimeter, building, observation systems); procedural (policies on leave, searches, visitors, communications, observation levels); relational (staff knowledge of the patient, alliance with firm boundaries, skill-mix, early detection of change). Relational security is the most important for therapeutic progress.^[1][3]

(ii) Assessing level for the prison referral. Use structured professional judgement multi-source assessment: gravity and pattern of violence (index and prior wounding when unwell), escape/abscond history (prior open-ward absconds), victim access, substances (methamphetamine), current mental state and insight, treatability/engagement, prison behaviour while settled on antipsychotic. Tools such as DUNDRUM-1 triage security (with urgency/DUNDRUM-2 if wait-listing) and complementary violence SPJ (HCR-20-style) inform level — not a single score or sentence length. Document formulation: who is at risk of what, when, and why this security level enables treatment. Do not invent statute section numbers for transfer powers.^[1][7][2]

(iii) High / medium / low principles. High: grave and immediate risk to the public; escape must not be possible. Medium: serious risk of harm to others; escape must be prevented. Low: significant risk; escape must be impeded. Choose the least restrictive level that still safely enables treatment. In ANZ regional services without separate high-secure estates, match need within available medium/low/community therapeutic security rather than maximising locks by default.^[1][6]

(iv) Long-stay step-down. Six years in medium secure with completed programmes, successful unescorted leave, and low dynamic risk signals probable excess security if no step-down plan. Long-stay is common (~one-fifth in English high/medium research samples) and often reflects system barriers as much as immutable danger.^[4] Convene recovery/step-down review: DUNDRUM-3/4-style programme and recovery evidence, HCR dynamic factors, leave success, housing/aftercare map; plan move to low secure/open forensic/community forensic outreach. Security level is dynamic.^[2]

(v) Pitfalls and aftercare. Pitfalls: over- or under-security; equating seclusion with secure care level; ignoring relational security; permanent branding by admission source; inventing legal sections. After discharge, meta-analytic evidence shows material reoffending, readmission, and excess mortality risks — plan forensic or appropriately intensive aftercare, crisis contacts, substance relapse prevention, and housing; aftercare model can influence trajectories.^[5][8]