Reaching a turning point--how patients in forensic care describe trajectories of recovery

Forensic Psychiatric Patients' Experiences of Personal Recovery: A Wilsonian Concept Analysis

ABSTRACT

Psychiatric patients' recovery processes have been studied rather extensively, and a relatively clear consensus on what recovery is already exists. We examined whether the personal recovery of forensic psychiatric patients varies from this definition. We conducted a concept analysis to assess the personal recovery of patients in forensic psychiatric hospitals based on 21 articles and then evaluated how our results compared with existing definitions on psychiatric and forensic recovery. On the basis of this comparison, we concluded that the personal recovery of forensic psychiatric patients does differ from that of other psychiatric patients. The recovery process of forensic psychiatric patients can be described through five themes: personal development and autonomy, social inclusion and normality, redemption and overcoming, future orientation and hope, and advancing process. The burden of a psychiatric disorder causes similar challenges, yet a criminal history and long hospitalization periods are distinctive issues for forensic patients, both of which can lead to severe alienation from society and deterioration of skills needed in life outside an institution. The results suggest that processing the criminal offense should be part of the care; furthermore, institutions should support forensic psychiatric patients in their reintegration into society and personal development. Identifying special recovery challenges can be useful when designing effective care and promoting the recovery of forensic patients. Thus, our results suggest that certain features of forensic psychiatric patients' recovery should be considered when planning their psychiatric care.

Reducing Risk for Future Violence From Forensic Psychiatric Patients by Using Critical Factors of the Short-Term Assessment of Risk and Treatability as a Caring Tool

BACKGROUND

The dual task for forensic mental health care is community protection and treatment of mental disorders. The Short-Term Assessment of Risk and Treatability (START) has become an established tool for risk assessment and care planning in forensic psychiatry. When using the START, items judged as critical factors are chosen to be addressed in the care plan. However, it is not known which critical factors that are of special interest need to be addressed to reduce the risk for future violence.

AIMS

The main aim of this study was to explore how staff's choice of critical factors in the care planning influences risk for future violence.

METHODS

The study is based on 787 START assessments from 285 convicted and involuntary admitted inpatients at the Forensic Psychiatric Clinic of Stockholm County, Sweden. The influence on risk for future violence by selecting a certain item as a critical factor in the care plan was measured by comparing patients' sum of vulnerabilities at the time this certain critical factor was selected with this sum at the next assessment.

RESULTS

The results show that a patient's overall risk for future violence decreases significantly when the items "insight," "attitudes," "mental state," "coping," and "drug use" were addressed as critical factors in the care planning. The importance of specified critical factors differs between diagnostic groups and time after admission.

CONCLUSIONS

When staff select certain specified items as critical factors in the care planning, the patients' risk of relapse into acts of violence was significantly reduced.

A shifting paradigm? A scoping review of the factors influencing recovery and rehabilitation in recent forensic research

Forensic research and practice have historically focused on risk assessment and prevention. This risk-oriented paradigm is shifting towards a more recovery-oriented perspective. The aim of this scoping review is to provide an overview of research on the factors influencing rehabilitation and recovery and discuss the recovery paradigm in a forensic setting. We performed a systematic search of the literature from the past 10 years, in Pubmed, Cinahl and PsycInfo, on recovery and rehabilitation. All types of study designs were included. Data was analysed and charted using an Excel template with various data items of interest. Clinical, personal, social, functional and forensic factors were found to be of influence on recovery and rehabilitation. A number of these overlapped with factors of influence on recidivism and desistance, others did not. Most studies on recovery and rehabilitation focused on a clinical forensic setting. This study provides an overview of the current body of knowledge on the factors influencing recovery and rehabilitation in forensic clients, and encourages researchers and practitioners in their focus on the recovery paradigm in forensic care. The body of evidence on rehabilitation and recovery is not yet as profound as that on recidivism and desistance. More knowledge on recovery trajectories for offenders in prison or ambulatory care, for example, is required.

The use of recovery model in forensic psychiatric settings: A Foucauldian critique

Recovery, a model of care aimed at patient-led nursing practice emphasizing autonomy, hope and self-determination, has in recent years been adapted for the secure forensic psychiatric setting. Often referred to as 'secure recovery', this model suggests the aims of recovery are achievable even in highly restrictive settings. This paper will adopt a Foucauldian perspective to offer a critical analysis of recovery in forensic settings. In providing recovery-oriented care, nurses utilize pastoral power in guiding patients to institutionally preferred outcomes. Akin to Christian religious conversion, nurses engage in a neo-religious conversion of patients to a neoliberal subjectivity of homo-economicus. This path of recovery is grounded in an ethos of personal responsibility and self-government, inseparable from the greater context of neoliberal governmentality. Despite attempts at transforming forensic nursing practice into more egalitarian directions, recovery remains a coercive practice, and fails to meet the overall goals of this paradigm in secure settings.

"You Should Just Keep Your Mouth Shut and Do As We Say": Forensic Psychiatric Inpatients' Experiences of Risk Assessments

This study presents findings of forensic inpatients' experiences of their role in the risk assessment process. Eleven patients, recruited from two forensic psychiatric clinics in Sweden, participated in semi-structured interviews which were analyzed using qualitative content analysis. The analysis of their experiences resulted in the information of three categories: Taking responsibility for one's own situation, in terms of taking responsibility for aspects of one's care, taking charge of the present, emphasizing potential challenges in grasping reality, and being involved and having impact, which concerns feelings of being involved in discussions related to one's care and treatment versus feelings of being an outsider.

Personal recovery and its challenges in forensic mental health: systematic review and thematic synthesis of the qualitative literature

BACKGROUND

There has been a call for a framework to guide recovery-oriented practices in forensic mental health services.

AIMS

This study aims to examine personal recovery and its challenges in forensic mental health settings in relation to the established framework for personal recovery in mental illness: connectedness, hope, identity, meaning and empowerment (CHIME).

METHOD

This study is an updated and expanded systematic review and thematic synthesis of the qualitative literature. A systematic search of six electronic databases (Web of Science, Medline, PsycINFO, CINAHL, EMBASE and SocIndex) was carried out in January 2019, using the terms [Recover*] AND [Forensic OR Secure] AND [Patient* OR Offend* OR Service User*]. Only studies that included service user's own perceptions and were published from 2014 onward were included in the review. Data were examined with thematic synthesis and subsequently analysed in relation to the CHIME framework.

RESULTS

Twenty-one studies were included in the review. Findings suggest that some adjustments to the original CHIME framework are needed for it to be more relevant to forensic populations, and that an additional recovery process regarding feeling safe and being secure (safety and security) could be added to CHIME, providing the CHIME-Secure framework (CHIME-S). Specific challenges and barriers for forensic recovery were identified and found to represent the opposite of the recovery processes defined by CHIME (e.g. hopelessness).

CONCLUSIONS

We present the CHIME-S as a framework for the personal recovery processes of forensic mental health service users. The CHIME-S may guide the recovery-oriented work of forensic mental health services.

Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

AIMS

To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

METHOD

Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

RESULTS

The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

CONCLUSIONS

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

DECLARATION OF INTEREST

None.

Feeling safe or unsafe in psychiatric inpatient care, a hospital-based qualitative interview study with inpatients in Sweden

Background

A major challenge in psychiatric inpatient care is to create an environment that promotes patient recovery, patient safety and good working environment for staff. Since guidelines and programs addressing this issue stress the importance of primary prevention in creating safe environments, more insight is needed regarding patient perceptions of feeling safe. The aim of this study is to enhance our understanding of feelings of being safe or unsafe in psychiatric inpatient care.

Methods

In this qualitative study, interviews with open-ended questions were conducted with 17 adult patients, five women and 12 men, from four settings: one general psychiatric, one psychiatric addiction and two forensic psychiatric clinics. The main question in the interview guide concerned patients' feelings of being safe or unsafe. Thematic content analysis with an inductive approach was used to generate codes and, thereafter, themes and subthemes.

Results

The main results can be summarized in three themes: (1) Predictable and supportive services are necessary for feeling safe. This concerns the ability of psychiatric and social services to meet the needs of patients. Descriptions of delayed care and unpredictable processes were common. The structured environment was mostly perceived as positive. (2) Communication and taking responsibility enhance safety. This is about daily life in the ward, which was often perceived as being socially poor and boring with non-communicative staff. Participants emphasized that patients have to take responsibility for their actions and for co-patients. (3) Powerlessness and unpleasant encounters undermine safety. This addresses the participants' way of doing risk analyses and handling unpleasant or aggressive patients or staff members. The usual way to act in risk situations was to keep away.

Conclusions

Our results indicate that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication could enhance patient perceptions of feeling safe. It seems to be important that staff provide patients with general information about the safety situation at the ward, without violating individual patients right to confidentiality, and to have an ongoing process that aims to create organizational values promoting safe environments for patients and staff.

'The Art of Understanding in Forensic Psychiatric Care' - From a Caring Science Perspective Based on a Lifeworld Approach

Patients in forensic psychiatric clinics are a vulnerable and exposed patient group due to suffering from a severe mental disorder, having committed a crime and being cared for against their will in an institutional environment with a high level of security. The art of understanding in forensic psychiatric care is discussed from a caring science perspective, based on a lifeworld approach. The aim is to contribute knowledge that can support staff, who daily meet patients on forensic psychiatric wards, in applying a caring attitude.

Forensic Psychiatric Patients' Perspectives on Their Care: A Narrative View

PURPOSE

The purpose of this study is to describe forensic psychiatric patients' experiences of and perspectives on forensic psychiatric treatment.

DESIGN AND METHODS

Eight forensic psychiatric patients were interviewed, and the resultant research material was analyzed by narrative analysis.

FINDINGS

Patients' narratives contain different themes telling different things and the personnel need to pay attention to these.

PRACTICE IMPLICATIONS

The findings of the present study should direct the forensic psychiatric personnel's attention to the notion that forensic psychiatric patients' experiences of their treatment can improve the quality of patient-centered care and reduce bureaucracy.

"It Had Only Been a Matter of Time Before I Had Relapsed Into Crime": Aspects of Care and Personal Recovery in Forensic Mental Health

INTRODUCTION

Forensic psychiatry has the dual task of focusing on the prevention of reoffending as well as maintaining psychiatric rehabilitation. No previous studies addressing the patients' own views on reducing their risk of serious reoffending were found.

AIM

This study describes forensic psychiatric inpatients' own views on what aspects of care and personal recovery are important in reducing their risk of serious reoffending.

METHODS

A structured qualitative approach was used. Data were collected from semistructured interviews and analyzed with a systematic qualitative content analysis.

RESULTS

The results highlight aspects of care and personal recovery. Four themes emerged: "time: opportunity for change," "trust: creating a context with meaningful relations," "hope: to reach a future goal," and "toolbox: tools needed for recovery."

DISCUSSION

The themes present with a continuum. At one end, there are patients who appreciated possibilities to participate actively in care and treatment. At the other end, patients felt they had no use for their care. Interestingly, although patients in our study were asked for their opinion on how they could reduce their dangerousness, all themes fit into established personal recovery processes found in general psychiatric populations. The theme "time: opportunity for change" seems to have an overarching importance.

IMPLICATIONS FOR PRACTICE

By understanding the specific content along these themes, relevant to the individual patient, carers may be able to better support their personal recovery journey. Because time spent as inpatients in forensic psychiatry is an overarching issue, carers need to be persistent over time.

Hermeneutic caring conversations in forensic psychiatric caring

Background:

In forensic psychiatric care, a hermeneutic caring conversation between caregivers and patients can improve health outcomes. The hermeneutic approach entails starting from the whole and involves openness for what is shown as well as paying attention to the different parts. One way to deepen these conversations is to take advantage of both the caregivers’ and the patients’ life experiences.

Research questions:

The purpose of the study is to discuss and reflect on what hermeneutic caring conversations can mean for a deepened understanding of the movement in the health processes of patients in forensic care, patients who are in deep suffering.

Research design:

This study uses a hermeneutic methodology. Conversations with patients receiving care in forensic psychiatry are deepened using texts from philosophy, caring science, and poetry. The outcome emerges through a phase of creating patterns.

Participants:

Three patients in forensic care.

Ethical considerations:

This study builds on a doctoral thesis approved by The Ethical Review Board at the Faculty of Medical and Health Sciences, Linköping, Sweden.

Findings:

Hermeneutic caring conversations provide a possibility for rich caring conversations with patients who are often not given a voice. These conversations are seen as ethical expressions of hermeneutic caring communion that affect patients’ health processes in a positive way.

Discussion:

It takes courage and responsibility to initiate and conduct these conversations as the patients volunteer to share their suffering. In hermeneutic caring conversations, the caregiver’s attitude is crucial for the transference of knowledge.

Conclusion:

This study provides a preliminary outline for hermeneutic caring conversations. A caring culture that provides time and space to prepare hermeneutic caring conversations is a prerequisite for the implementation of hermeneutic caring conversations.

Reducing violence in forensic care - how does it resemble the domains of a recovery-oriented care?

BACKGROUND

Forensic psychiatry is characterized by involuntary treatment and risk of violence. The concept of recovery is rarely in focus as the primary focus is on risk assessment, violence prevention and reducing coercion in care.

AIM

To determine what resources forensic staff use to avoid or prevent violent situations, and to explore how these practices resemble the domains of recovery-oriented care.

METHOD

Semi-structured interviews with staff who were identified by forensic patients as key workers in their recovery process. Interview texts were analyzed using interpretive content analysis.

RESULTS

Staff prevent violent situations using tacit knowledge and experience, and through a shared collegial responsibility. Staff safeguard patients, encourage patient participation, and provide staff consistency.

CONCLUSIONS

The results have implications for forensic care as well as psychiatry regarding the process of making recovery a reality for patients in the forensic care setting.

Reducing or increasing violence in forensic care: a qualitative study of inpatient experiences

Semi-structured interviews with 13 forensic psychiatric inpatients that had decreased their assessed risk of violence were analyzed using interpretive description. The main contribution from this study is a detailed description of patients' own strategies to avoid violence. Participants described having an ongoing inner dialog in which they encouraged themselves, thereby increasing their self-esteem and trying to accept their current situation. An unsafe and overcrowded ward with uninterested and nonchalant staff increased the risk of aggressive behavior. In the process of decreasing violence, the patients and the forensic psychiatric nursing staff interacted to create and maintain a safe environment.

Caring Science and the Development of Forensic Psychiatric Caring

PURPOSE

This study aimed to discuss how caring science can contribute and provide a theoretical foundation for the development of caring within forensic psychiatric care.

CONCLUSIONS

It is not only a challenge but also a great opportunity to use caring science theory within forensic psychiatric care when caring for the patients and supporting their health processes.

PRACTICE IMPLICATIONS

There is a need for more knowledge about, understanding of, and willingness to care for patients within forensic psychiatric settings in a "true caring" way. In order to achieve this, a caring culture is required, one that supports carers and provides them with opportunities to further develop a caring attitude.

Caring potentials in the shadows of power, correction, and discipline - Forensic psychiatric care in the light of the work of Michel Foucault

The aim of this article is to shed light on contemporary forensic psychiatric care through a philosophical examination of the empirical results from two lifeworld phenomenological studies from the perspective of patients and carers, by using the French philosopher Michel Foucault's historical-philosophical work. Both empirical studies were conducted in a forensic psychiatric setting. The essential results of the two empirical studies were reexamined in a phenomenological meaning analysis to form a new general structure in accordance with the methodological principles of Reflective Lifeworld Research. This general structure shows how the caring on the forensic psychiatric wards appears to be contradictory, in that it is characterized by an unreflective (non-)caring attitude and contributes to an inconsistent and insecure existence. The caring appears to have a corrective approach and thus lacks a clear caring structure, a basic caring approach that patients in forensic psychiatric services have a great need of. To gain a greater understanding of forensic psychiatric caring, the new empirical results were further examined in the light of Foucault's historical-philosophical work. The philosophical examination is presented in terms of the three meaning constituents: Caring as correction and discipline, The existence of power, and Structures and culture in care. The philosophical examination illustrates new meaning nuances of the corrective and disciplinary nature of forensic psychiatric care, its power, and how this is materialized in caring, and what this does to the patients. The examination reveals embedded difficulties in forensic psychiatric care and highlights a need to revisit the aim of such care.