To break the cycle of readmissions and or reoffending, it takes a combination of effective treatment and individualised care by a team of skilled individuals from different disciplines. Maslow’s hierarchy provides a clinically coherent framework to balance care, containment, and recovery. 

Progression through the hierarchy is generally slower, non-linear, and risk-informed, but still essential for the better health outcomes for the individuals and the wider community.  

1. Physiological needs

As simple as this may seem, individuals with severe mental illness often struggle to achieve this basic level. Self care is often limited with poor diet and sleep disturbance. 

In secure settings, this level equates to clinical containment and biological stabilisation where active psychotic symptoms or mood disturbance acts as a barrier. To be able to achieve this, adequate symptom control is the key, and this may need optimisation of medication (first generation when second generation antipsychotics are ineffective, use of depot medication to ensure compliance) and clozapine when indicated. Inpatient/secure settings are best placed to initiate clozapine as compliance can be facilitated for an extended period of time. Clozapine helps to achieve better symptom control which in turn means higher chances of recovery.  

In addition to having their own room that can be secured from inside, safe communal space, individuals require monitoring and managing of metabolic syndrome, structured sleep–wake routines, regular meals with nutritional oversight, assistance with hygiene and personal care, and physical health screening (cardiovascular risk, diabetes, smoking etc.). 

The environmental structure of the secure setting compensates for impaired executive functioning and provides physical security, at least in the early phase of rehabilitation. Similarly, a stable accommodation with or without supports remains a prerequisite for discharge to ensure that recovery is maintained in the community. 

2. Safety and security needs

This aspect of rehabilitation is rather unique to secure mental health facilities. It includes risk containment while offering psychological safety to this group of individuals. Most individuals should be able to reach this level soon after their admission.  

People with schizophrenia in secure care often have paranoid ideation, trauma histories (including prior restraint/seclusion) and poor insight into risk. Here, the relational aspect of security plays a major role. Staff training in understanding relational security and applying it in principles is crucial to achieve this stage.

Key interventions during this phase: consistent staffing and predictable routines, clear boundaries and transparent rules, individualised risk formulations, positive behaviour support plans, trauma-informed care approaches, effective de-escalation strategies and minimal use of restrictive practices. Security must feel protective, not punitive and focus on safety/ security needs tends to diminish as individuals progress in their individual recovery journey.  

3. Love and belonging

Aim during this rehab phase is to counteract social isolation and institutional identity that most individuals experience. Love is viewed in a broader sense and not just in a romantic sense/intimate relationship although these could be supported depending on the individual's circumstances. This stage should commence as soon as psychosis/mood disturbance (controlling their emotions and behaviour) is no longer a dominating feature. 

Schizophrenia is commonly associated with impaired social cognition (understanding facial expressions/social aspects of situations) and specific interventions like SCIT (social cognition and interaction training) can address such deficits. Allied health staff play a major role in achieving rehab goals in this phase by offering therapeutic group programs (CBT-p, social skills training, cognitive remediation etc). Peer support, family involvement/visiting programs, staff–patient relational continuity, ward community meetings/groups, culturally responsive care are all important aspects of the recovery journey in this phase and are guided by dynamic risk assessments. 

Some individuals prefer a one to one approach, especially if paranoia is persistent or they are experiencing negative syndrome. Gradual exposure to group settings may be needed. 

4. Esteem needs

This phase in rehab overlaps with the previous one and is distinguished by the active preparation for transition into the community and helping them attain skills to live a more meaningful life. 

Here, the rehab needs are met by vocational training, education and skills training (e.g. TAFE), supported decision-making (capacity building), gradual increase in responsibility (e.g. supervised or unescorted leave,overnight leave), with focus on relapse prevention and self-confidence

Secure rehab settings should encourage strengths-based formulation and activities (music, art, cooking, gardening, sports, construction/ labouring, writing, any other specific skill etc) to help individuals build on their skills and self esteem, based on their strengths and interests. When individuals are able to achieve this level of rehab standards, it is reflective of good prognosis and the higher odds of capacity for independent living with minimal to moderate level of supports in the community

5. Self-actualisation

Self-actualisation for someone with severe mental illness in secure care does not necessarily mean symptom-free structured functioning, but rather living with purpose, developing an identity beyond diagnosis and offence, and hope for a future outside of the secure walls.

This is the highest level of rehab goal that can be achieved and some may even take up patient advocacy or leadership roles. Others may not be able to reach this point depending on their complexities and cognitive reserves. Prolonging admission in an expectation to push individuals to this level can be counterproductive and can in turn risk dependency and institutionalisation. 

Integrating Maslow’s principles with risk management
In secure mental health rehabilitation, a deeper understanding of these principles can guide the individualised rehabilitation by incorporating holistic (bio-psycho-social and cultural) approach.

While it is natural for staff to expect and want to see all patients improve and progress, it is important to remember that some patients will relapse and may require returning to lower levels. Not recognising early warning signs when individuals are progressing well, can be detrimental and it may take much longer for them to return to their previous functioning, lowering their self confidence and increasing the length of stay (possibly risking institutionalisation). Equally, using an overly cautious approach may act as a barrier towards a successful rehab. 

Staff often attribute behavioural issues as stemming from a personality disorder to allow individuals to be held accountable for their actions. Caution must be taken for those who have a diagnosed severe mental illness and any change in behaviour must alert staff to carefully reassess the change in behaviour pattern as that could be early warning signs for relapse. 

Again rehab is a non linear process and guided by a range of factors including illness related, patient related, staff related and systemic functioning. When there are a number of identified barriers, goals may need to be reappraised depending on the individual needs. Regardless of any setbacks, individuals should require less security with time and as they progress in their recovery journey. 

From my experience, something is generally missing from the management plan (could be biological/ psychological/ social/cultural or even spiritual) if individuals cannot move ahead despite numerous attempts. In those situations, we may need to intensify treatment plans and consolidate the gains before moving them up the rehab journey.

References
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