Therapeutic security and secure care levels — structured clinical viva

Definition. Therapeutic security integrates physical, procedural, and relational measures so that people with mental disorder who pose serious risk can be treated safely. Dual purpose: clinical recovery and public protection — not punishment.^[1]

Three domains. Physical/environmental shell; procedural policies that structure risk-critical behaviour; relational security — staff knowledge, alliance with boundaries, early detection. Relational is most important for therapeutic progress and is measurable (STA).^[3][4]

Levels. High: grave and immediate; escape not possible. Medium: serious risk; escape prevented. Low: significant risk; escape impeded. Always apply least restrictive level that safely enables treatment.^[1][8]

Placement assessment. SPJ multi-source assessment; DUNDRUM-1 security triage, DUNDRUM-2 urgency, later DUNDRUM-3/4 for programmes and recovery; HCR-20-style tools complement but answer different questions. Systematic review supports structured approaches to secure admission assessment.^[1][2][9]

Step-through and long-stay. Security need is dynamic; programme completion and recovery metrics support moves.^[2][10] Long-stay ~1/5 in English high/medium research samples — treat stalled pathways as a system problem requiring active review.^[5]

Restrictive practices. Necessary, proportionate, time-limited; DRILL-style ladders of restriction, intrusion, and liberty — not a substitute for correct security level.^[7]

ANZ caveat. Regional services may lack separate high-secure campuses; match high-need patients using therapeutic security configuration within available estate (Jewell NZ teaching point).^[8]

Discharge. Meta-analysis shows material reoffending, readmission, and excess mortality after secure discharge — aftercare is part of security planning.^[6]

Legal hygiene. State principles only; never invent statute section numbers. Placement and transfer powers are jurisdiction-specific; teach matching of therapeutic security need rather than quoting invented sections.^[1][8][9]