The start of the day varies working as a forensic registrar in a Prison Mental Health service in Far North Queensland. Five days a fortnight, the day starts early, arriving in the office at 7am for the 1.5 hour trip to Lotus Glen Correctional Centre alongside the consultant and several case managers. Lotus Glen Correctional Centre is a male high security prison based in the Tablelands of far north Queensland; built to sustain a capacity of 396, it regularly houses in excess of a thousand prisoners. The winding road bypasses some of the region’s majestic rainforest, and a few times we have been fortunate to spot cassowaries and even deer strolling near the road. The trip is usually punctuated by a coffee stop to sample the region’s locally grown coffee.  

Once we arrive at the prison, we pass through several layers of security, having fingerprint scans and metal detection screening similar to the airport, before buzzing through several heavy locked doors. We collect our duress alarms and are greeted warmly by the QCS officers and a few prisoners who are working in the clerking area, dressed in regulation green shorts and shirts. We set up for the day in the medical block, collecting our patient files, medication charts and lists. The nurses and GP covering the service will often catch us up on any new patient concerns, and an on-site pharmacy covers all the medication issues.  

My first task is clozapine clinic for a patient serving a life sentence for murder, followed by an hour long session of impromptu CBT for a patient who has been self-medicating his PTSD with illicit drugs, and struggling now he no longer has access to his usual central nervous system depressants. I review a highly psychotic patient who is being housed in the safety unit while we await a hospital bed to become available for him, and increase his medication after he reports he still has command hallucinations to sacrifice his cellmate for God. After a lunch cooked by the prisoners in the staff room, I spend my afternoon reviewing a few malingering patients who are seeking an assortment of benzodiazepines, opioids and the reinstatement of their medicinal cannabis.  

There are a fascinating range of patient presentations in the prison setting. When I was first allocated the term, I was trepidatious about how I would manage working with the prison population. Would I be able to manage my countertransference towards people charged with murder, or violent crimes against children? Despite my concerns, I was able to find great depths of empathy, sympathy and therapeutic alliance with most of my patients. 

Many had suffered extensive trauma and grown up in dysfunctional homes characterised by neglect, substance abuse, violence and repeated incarceration; they lacked the material and psychological resources to escape this cycle of intergenerational trauma. There were several patients who had committed offences in the context of psychosis or mania which was detected for the first time in prison. They were often itinerant and disadvantaged, with no access to healthcare services or supportive family or friends to encourage them to seek treatment. Working in the prison highlighted how social determinants of health dictate the trajectory of people’s lives, and presented a unique opportunity to try to shift direction for some of them. Providing care to a population who are usually incredibly marginalised was a real privilege.   

There was also a great opportunity to work with First Nations people, and at least 90% of the inmates at Lotus Glen Correctional Centre are Aboriginal and/or Torres Strait Islander, starkly underscoring the need to address First Nations overrepresentation within our justice system. Working alongside the cultural liaison officers and Indigenous mental health workers, and organising cultural healing such as smoking ceremonies for some of our patients was a great experience in expanding my knowledge and appreciation of working with this population.  

After we returned to the office, I collated my notes ready to transcribe into patient’s electronic medical records; on the other 5 days of the fortnight I am based in the office with meetings, multidisciplinary team gatherings and note and report writing taking priority. At times, I join the Community Forensic Outreach Team to conduct comprehensive risk assessments and management plans, or arrange medication for people being held in the Watchhouse. As a registrar I am not required to write court reports or get called to court, but there are many lively discussions in supervision with my consultant about fitness to plead, nuances of criminal law and responsibility, and the complexities of mental health court. I would never have envisioned myself working in a prison, but I leave every day looking forward to what I will learn and discover the next.  

By Elise Witter, Remote Registrar and Stage 2 trainee, Child and Youth Mental Health Services.