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.
On this page & tools
Target exams
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]
Candidate scenario
The consultant says: "He stabbed someone when psychotic. I'm not having my nurses assaulted. Put him in high secure today or I'll keep him secluded all week. Forensic always underplays risk." Your notes: single serious assault when floridly psychotic and intoxicated; now partially treated; no escape attempts this admission; regional service has medium/low secure beds and no co-located high secure hospital. [1][4]
Marking domains
- Empathic alliance with colleague without colluding with indefinite seclusion as "placement"
- Explains three domains of therapeutic security in plain language
- Correct high vs medium principles (grave/immediate vs serious risk)
- Least restrictive matching; not maximising security by default
- Interim plan: relational and procedural measures on current ward while referral proceeds
- Restrictive practices framed as time-limited and proportionate, not a secure-care substitute
- Mentions later step-down/recovery goal of secure care
- Checks understanding; agrees joint safety actions and information needed for triage [1][2][3][6]
Reveal assessor key
Open. Acknowledge the assault risk and staff fear. Align on shared goal: keep patients and staff safe while treating psychosis. Thank them for escalating early. [1]
Reframe high secure. High secure is for grave and immediate public risk where escape must not be possible — not an automatic label for every serious assault. Many such patients are appropriately managed in medium secure care (serious risk; escape prevented) if therapeutic security is strong. Our region matches need within medium/low/community resources using structured assessment — maximising locks is not the same as safer care. [1][4]
Therapeutic security explained. Safety is physical environment + procedures (observation, leave, searches) + relational security — knowing this man, his triggers, early warning signs, and consistent MDT approach. Seclusion alone is not a security level. [2][3]
Interim plan tonight. Optimise treatment of psychosis; agree observation intensity; remove weapons/means; limit leave; increase skilled engagement; review seclusion if used so it remains necessary, proportionate, and time-limited with exit criteria — not all-week default. We will complete structured forensic referral (offence detail, substances, mental state, abscond history, victim issues) so triage of therapeutic security level is accurate. [1][3]
Longer view. Once placed, the aim is treatment, recovery programmes, and step-down as dynamic risk falls — secure care is not meant to be a life sentence in high containment. Discharge later still needs aftercare because post-secure outcomes are not risk-free. [5][6]
Close. Agree who does what in the next 24 hours, what information nursing will escalate, and when you will update on bed triage. Check the consultant's understanding and thank them for partnership. No invented legal section numbers. [1]
References
- [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]Chester V, Alexander RT, Morgan W. Measuring relational security in forensic mental health services BJPsych Bull, 2017.PMID 29234515
- [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]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]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]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