The Treatment Perspectives of Mentally Ill Offenders in Medium- and High-Secure Forensic Settings in Flanders

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

Voices to be heard: Understanding family perspectives in forensic care trajectories

INTRODUCTION

De-institutionalization of psychiatric care has greatly increased the role of family members in the recovery pathways of Persons labeled as Not Criminally Responsible (PNCR). However, the role of family members in supporting PNCR in forensic psychiatric care remains understudied. Scarce evidence indicates that PNCR have to deal with stigma and endure specific burdens (i.e., symptom-specific, financial, social, and emotional). Recovery-focused research showed that recovery in both persons with a severe mental illness and family members develop in parallel with each other and are characterized by similar helpful principles (e.g., hope and coping skills). As such, the recovery pathways of PNCR often goes hand in hand with the recovery pathway of their family members. During the family recovery process, family members often experience not being listened to or being empowered by professionals or not being involved in the decision-making process in the care trajectory of their relative. Therefore, the aim of this study is to capture how family members experience the care trajectories of their relatives, more specifically by looking at family recovery aspects and personal advocacy of family members.

METHODS

Semi-structured interviews were conducted with 21 family members of PNCR from 14 families. A thematic analysis confirms that family members suffer from stigma and worry significantly about the future of their relative.

RESULTS

Regarding the care trajectory of PNCR, family members experienced barriers in multiple domains while trying to support their relative: involvement in care and information sharing, visiting procedures, transitions between wards, and the psychiatric and judicial reporting by professionals. In addition, family members emphasized the importance of (social) support for themselves during the forensic psychiatric care trajectories and of a shared partnership.

DISCUSSION

These findings tie in with procedural justice theory as a precondition for family support and family recovery within forensic psychiatric care.

Exploring the Experiences of Male Forensic Inpatients' Relationships with Staff within Low, Medium and High Security Mental Health Settings

Therapeutic relationships within psychiatric settings are highlighted as important throughout the literature. However, research from the forensic inpatient perspective is limited. We address this gap by exploring the patient-staff relationships within forensic mental health inpatient services, from the patient's perspective. Thirty adult male forensic inpatients were interviewed about their experiences on the ward and their interactions with staff. Our analysis examines inpatients experiences of respectful and reciprocal relationships, relationships that empower, a disinterest in their patients' and authoritarian relationships. This study concludes by highlighting the need to prioritise the development of reciprocal relationships within forensic services.

Crushed by the Belgian system: Lived experiences of forensic care trajectories by persons labelled as not criminally responsible

BACKGROUND

Care trajectories of Persons labelled Not Criminally Responsible (PNCR) are often characterized by multiple transitions from one (forensic) mental health service to another and by long periods of admission. So far, little research has been conducted on forensic care trajectories, in particular on how PNCR perceive the trajectories they are subjected to.

METHOD

Data were obtained via semi-structured interviews (N = 23) with PNCR in various (forensic) mental health services in Belgium. A maximum variation sampling strategy was applied to recruit a heterogeneous group of PNCR and inductive thematic analysis adopted to analyse the data.

RESULTS

PNCR's experiences about care trajectories in Belgium are marked by an absent voice and passive position in the decision-making process in addition to a lack of support during transitions. Barriers for admission in (forensic) mental health services and the indeterminate duration of care trajectories contribute to overall negative lived experiences.

CONCLUSION

Although some findings are interchangeable with general mental health care, PNCR's care trajectories differ by their undetermined nature, barriers for accessing care and power dynamics in compulsory forensic care. As concepts from prison sociology, such as tightness, power holders and pain of indeterminacy, seem to be equally relevant for the situation of PNCR, the balance between a criminal justice and mental health approach in forensic mental health care is questioned.

Recovery of Offenders Formerly Labeled as Not Criminally Responsible: Uncovering the Ambiguity From First-Person Narratives

The recovery paradigm is a widely accepted strength-based approach in general mental health care. Particular challenges arise when applying this paradigm in a forensic context. To address these issues, the present study examined recovery based on first-person narratives of offenders formerly labeled as not criminally responsible of whom the judicial measure was abrogated. Eleven in-depth interviews were conducted to obtain information on lived experiences and recovery resources of this hard-to-reach and understudied population. The interviews focused on recovery and elements that indicated a sense of progress in life. Key themes were derived from the collected data. Descriptions of recovery resources followed recurrent themes, including clinical, functional, social, and personal resources. Participants also reported ambiguous experiences related to features of the judicial trajectory. This was defined as forensic recovery and can be seen as an additional mechanism, besides more established recovery dimensions, that is unique to mentally ill offenders.

The bumpy road to change: a retrospective qualitative study on formerly detained adolescents' trajectories towards better lives

BACKGROUND

Currently, the risk-oriented focus in forensic youth care is increasingly complemented by a growing interest in strengths-based approaches. Knowledge on how detention and the subsequent period in the community is experienced by adolescents, and which elements are helpful in achieving better lives can contribute to this emerging field. The current study aimed to retrospectively explore adolescents' experiences from the moment they were detained until 6 to 12 months after they left the institution, identifying positive aspects and strengths.

METHODS

In-depth interviews were conducted with 25 adolescents (both boys and girls, 15-18 years old) on average 8 months after discharge from a closed institution in Belgium. A thematic analysis was performed using NVivo 11.

RESULTS

Five themes and corresponding subthemes were identified: (1) adolescents' own strengths and resilience, (2) re-building personally valued lives, (3) making sense of past experiences, (4) moving away from a harmful lifestyle, and (5) (in-)formal supports. Most adolescents are on their way to finding a new balance in life, however, for a subgroup of them, this is still fragile. Adolescents highly emphasize the importance of feeling closely connected to at least one person; to receive practical help with regard to finances, work and housing; and to be able to experience pleasure and joy in their lives.

CONCLUSIONS

Adolescents' narratives suggest that starting a journey towards a normative good life often goes along with an initial difficult period because of a sense of loss with regard to their former life. This stresses the importance of targeting rehabilitation towards prosocial goals and enhancing adolescents' quality of life on those life domains that matter most for them. Furthermore, we stress the importance of helping adolescents in overcoming structural barriers as a first step in supporting them in their trajectories towards better lives.

Experiences of restrictiveness in forensic psychiatric care: Systematic review and concept analysis

Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.