Increasingly, secure forensic mental health services must balance reducing restrictive practices on one hand with keeping a violence free environment on the other. Nursing staff and other hospital staff have the right to work in a safe environment. They should not be subject to intimidation and assaults in the work setting. Patients have the right to care in a safe environment and they need to have confidence that staff members can keep them safe during their in-patient stay. Minimising in-patient violence and minimising past violence for forensic patients is undermining an area of significant treatment need and may seriously limit the patient’s chance of a future successful discharge in the community. We posit in this chapter that active and careful management of ward milieu and dynamics, and active treatment of psychotic and other symptoms, together with proportionate use only of restrictive practice and thorough evaluation of any and all restrictive practice is the most effective way of managing a forensic in-patient setting to effectively reduce and prevent incidents of violence.

Patients with borderline personality disorder often pose challenges in various inpatient settings. It is becoming more common for the patients that exhibit severe disturbed or high-risk behaviour within the context of this diagnosis to be transferred to psychiatric intensive care units (PICUs). The role of the PICU is widely regarded as one which can provide focused, short-term interventions for high-risk patients with mental illness; therefore, the very nature of borderline personality disorder contradicts such admission criteria. This chapter provides an overview of the common presentation and complexities of this patient demographic in a PICU and provides suggestions for management strategies. The chapter also advocates an emphasis on professionals being mindful of the patient pathway from PICU to discharge, with the aim to avoid a counterproductive admission which results in containment and overly restrictive practices.