Forensic mental health aftercare refers to service provision to persons or individuals who will have been diagnosed with a mental disorder and pose a risk to others  . In Zimbabwe, the transition of patients with mental health problems from high and medium security institutions to the community has always been unclear  . There also seems to be lack of fluidity, coordination, support and liaison between general and forensic mental health services. An exploration of the fragmented forensic mental health services was done. Services seemed to be there but not known or understood by important stakeholders and the general public of Zimbabwe.
Twenty-nine (29) participants were purposively drawn for the study. These were stakeholders that were regarded as information rich with regards to forensic mental health care. Participants included those from the judiciary who were directly responsible for the processes that involved persons who committed crimes because of mental illness. Ten (10) judiciary participants included public prosecutors, Magistrates, clerks of the court, members of the Mental Health Review Tribunal and superintendents of special institutions. Eleven (11) medical personnel who were part of the rehabilitation processes in special institutions were also part of the study. Eight (8) mentally stable forensic psychiatric patients awaiting discharge by the Mental Health Review Tribunal also participated in the study. A descriptive qualitative research design was used. Data were collected using semi-structured interviews. The goal was collection of rich information from various sources to gain a deeper understanding of forensic mental health aftercare in Zimbabwe. The method of analysis involved inductive exploration of data to identify recurring themes and patterns that described and interpreted community forensic mental health in Zimbabwe.
Permission to conduct the study was sought and granted by the following entities; The National Prosecuting Authority, Judicial Service Commission, Medical Research Council in Zimbabwe and the office of the Commissioner for Zimbabwe Prisons and Correctional Services (Department of Research and Development). Individual consent was also obtained from participants.
4. Findings of the Study
Three distinct functional community forensic mental health aftercare facilities were identified by the study. The facilities linked special institutions, civil psychiatric hospitals and the community. The centers include Tirivanhu Rehabilitation Centre, Tariro Rehabilitation Centre and Queen of Peace Rehabilitation Centre.
4.1. Main Source of Referral for the Identified Facilities
Patients with mental health problems are referred from varied sources but the main one is the Mental Health Review Tribunal. The Tribunal is a quasi-legal body formed and executed in terms of the Mental Health Act of 1996 Section 75. One of the Tribunal’s main functions includes directing release of patients detained in Special institutions in terms of the Act. Section 107 of the Mental Health Act is the one that specifies declaration of a place in lieu of special institution. The Minister of Health and Child Care and the Minister of Justice, Legal and Parliamentary Affairs through the Gazette liaise to declare that any institution is a Special institution. Two such institutions include Chikurubi and Mlondolozi prisons. It is from such institutions that patients are released by the Mental Health Review Tribunal to identified forensic mental health aftercare facilities.
The Main Partner in Forensic Mental Health Aftercare
Zimbabwe National Association for Mental Health (ZIMNAMH) is a registered private voluntary organization which started operating in 1981. The organisation was borne out of the realization that there was need for rehabilitation support that would bridge the gap between a care facility and the community. The organization’s thrust is bridging the gap between the institutions and the community. Clients are discharged from the Hospital or special institution through the organisation’s community facilities on their way to their original homes in the community. The association works with other partner organizations and half way homes.
4.2. Tirivanhu Rehabilitation Center
The center is run directly by ZIMNAMH. It offers half way services and rehabilitation services to its clients. It offers a very structured rehabilitation process. The center enrolls clients/patients for about 18 months’ maximum depending on the reason for admission. The source of referrals includes forensic mental health institutions, civil institutions, department of social welfare from other institutions.
4.2.1. Services Offered
When Tirivanhu Rehabilitation center admits a client, the first port of call is to educate them on their condition and try to help them in understanding and managing their own condition. This includes issues to do with the medication they are taking, why they are taking it and the importance of adhering to their medicines. A holistic assessment is done on the patient’s socio-economic functioning and identification of skills they may need improved on. The facility then works with them on social skills, activities of daily living and livelihood skills making it a whole package. Tirivanhu has a number of activities in terms of equipping clients/ patients’ livelihood skills.
4.2.2. Livelihood Skills
Livelihood skills revolve around agro based activities such as horticulture and small livestock production. There is general farming as well like vegetable gardening. Some services are outsourced for those clients who may not be interested in agriculture related kind of activities and might be interested in clothing or woodwork or even in art. For such activities, Tirivanhu as it is situated in Ruwa coexists with a number of vocational training centers that offer such skills. That means for those skills that the facility is not offering directly, it actually facilitates clients’ enrolment to those vocational skills training centers. They then go to those facilities during the day to attend the training and come back to the center in between. When patients are not at those institutions the facility continues with psychosocial skills rehabilitation. Clients also engage in house hold duties like cooking and other related activities of daily living to foster independence and relevance in the communities to which they are discharged. Tirivanhu Rehabilitation Centre has no gender prejudice and stereotypes, the training is generic, that is, it offers same and equal chances in their training for men and women.
4.2.3. Other Services
The facility engages in individual and group counselling and or therapy. The individual therapy approach at the facility is very much individualized as much as the facility offers a very generic rehabilitation programme. Individual therapy is tailored to the individual clients’ background and circumstances. The therapist’s endeavor is to pick areas that need psychological intervention for each and every individual client then address it. For those who might be exposed to violence, those issues are attended to and appropriate referrals made if need be.
4.2.4. Challenges and Future Projections
The center does occasionally engage other service providers like HIV and Aids reproductive health for women to address the specific need for females. The facility hopes to have such programs as part of its main service provision. Noted discharge success is biased towards women as opposed to males. At the point of discharge, the center finds it very easy to discharge female clients, the community seems to be ready to accept them as opposed to male patients. This could be due to the variances in the nature of crimes committed by both groups. Men tend to commit more heinous crimes than women hence their rejection  . The microeconomic environment has affected Tirivanhu’s funding especially with regard to its income generating projects. The center used to have viable projects but during the recent hyper-inflation period, it lost its equipment. The Centre is in the process of rebuilding those income generating projects that are not as viable as they used to be.
Funding is diverse; there is support from the government particularly the department of social services. Tirivanhu also gets what is called per capita grant to help their day to day daily requirements or provisions such as food, toiletries and a bit of clothing from the Ministry of Health and Child Care. The center also gets support from the donor community. Internal income generating activities at the center also contribute to the upkeep of activities in the facility.
4.3. Tariro Rehabilitation Centre
Tariro Rehabilitation Centre is located in Harare. It is also an affiliate of ZIMNAMH. The facility has two arms, Tariro Beatrice and Tariro Glenview.
4.3.1. Tariro Glenview
The Glenview facility is the entry point for forensic psychiatric patients who would have been referred by the Mental Health Review Tribunal (MHRT). It also receives patients from civil psychiatric hospitals referred by social workers. At Tariro Glenview, an assessment of the patient is made for insight into illness, social and livelihood skills. Patients received from prison/special institutions following the recommendation of the MHRT are usually those whose relatives are not willing to take back because of the nature of the crimes previously committed or those that the Tribunal perceives as needing more rehabilitation before joining the community.
For women, common crimes they would have committed include assault while the typical male has an attempted or actual murder case. The Glenview arm of the Tariro Rehabiliation Centre trains the patients on self-care, grooming and other activities of daily living. The facility equips patients with social skills that include how to live with other people, attending funerals, how to respond to conflict and other such skills. The Centre also focuses on home visits, follow-up of discharged patients and initiating and participating in awareness campaigns. Family conferences are conducted in Tariro Glenview whereby family members come and conduct extensive discussions and education about the patient. The aim of this exercise is to help relatives of patients who would have committed crimes to accept them. The need for this was borne out of the realization that patients stay up to more than the expected 18 months if such efforts are not made.
Counselling sessions are also done at this center utilizing the individual approach. Another social skills training and reintegration effort include going to the clinic on their own for any medical problems that patients may happen to have. Tariro Glenview has a garden which serves domestic consumption only.
4.3.2. Tariro Beatrice
When the staff at Glenview has assessed and equipped the patient with requisite social skills, the patient moves to Tariro Beatrice for livelihood skills training. This facility arm is considered as the commercial or project area. The facility runs a commercial garden, a field and a tuck-shop. Other livelihood activities include rearing of goats, ‘road-runner’ chickens and hares which are then sold to the public. Fence making and operation of a grinding meal are part of trainings that are given to patients
Most of the staff members are social workers and nurse aides.
The Rehabilitation Centre is funded by the Ministry of Health and Child Care.
3) Challenges and future projections
The facility has since suspended the bed manufacturing project as it needs more capital. The facility needs more capital to boost and maximize the functional capacity of its projects because at the moment it is breaking even.
4.4. Queen of Peace Rehabilitation Centre
It is a Centre that was established in 2006 as a halfway home in Gweru, Midlands Province. The overarching goal for the Centre is to prevent recidivism post discharge from special institutions. It basically functions as a bridge between the prison settings and the community.
4.4.1. Services and Activities
Reassessment of patients to identify patients’ needs and retrain lost skills in preparation for community reintegration is done at this centre. This is done through various psychological therapies that include occupational therapy, behavioral therapy and cognitive behavioral therapy. The Centre also advocate for re-employment of patients by previous employers or wherever the clients would have got employment.
4.4.2. Women Specific Rehabilitation
Most women who are placed in this facility would have killed their children. An evaluation of how they interact with children is imperative before they are released into the community. Observation of these mothers is done on what triggers their anger and anger management sessions are offered. Retraining is done to them on child rearing skills. This is done by giving the women monthly rotations at the Crisis Center. The Crisis center is a children’s wing within Queen of Peace Rehabilitation Centre. These children would have been brought by the social welfare department for various reasons or it could be those children under 18 who commit crimes but are too young to be sent to Tirivanhu or Tariro Rehabilitation centers. So, it is these children whom the women under rehabilitation take care of. They bath the children, make sure they are ready for school, prepare food for the children and sleep with the children. These activities are done under the guidance of a therapist.
4.4.3. Those Rejected by the Community
There are those patients who would have committed crimes of a high magnitude such that the community and families simply can’t accept them back. For such patients, Queen of Peace Rehabilitation Centre facilitates resettlement opportunities by offering a piece of land where they build pole and mud huts and stay with their families doing some little farming.
4.4.4. Church Involvement
Patients are encouraged to attend church as a way of facilitating interaction with community members. Pastors are engaged in this exercise to deal with issues of forgiveness targeting both the community members and the patients themselves. This way, a multi-sectoral and multidisciplinary approach is applied towards holistic care.
The Queen of Peace Rehabilitation Centre is dependent on donations from well-wishers. The farm produce sales also partly sustain the Centre. Services are offered by volunteers and students on attachment.
Ministry of Health and Child Care plays a part by treating patients from Queen of Peace Rehabilitation Centre free of charge for any medical condition or admission. Midlands State University Department of Psychology attaches its students at Queen of Peace Rehabilitation Centre. These assist with application and implementation of psychological therapies to patients at the center.
Needs of the forensic mental health population differ from that of the civil mental health population because of the inherent risk to relapse and recommit crimes  . In view of this risk, continuity of care within forensic mental health services should not be disrupted. Care and follow-up of patients discharged from special institutions in Zimbabwe are uncoordinated and parallel with mainstream mental health services. The thrust of this study was to identify and create awareness for the mental health fraternity about available resources for continuity of care for patients with mental health problems who would have committed crimes. There is need for development of policy frameworks that foster clear pathways for forensic mental health aftercare. Support and funding of efforts made by existing facilities are also imperative. It is recommended that identified facilities integrate with generic community teams in the Ministry of Health and Child Care for achievement of comprehensive forensic mental health aftercare objectives.