Offense-Related Issues in Forensic Psychiatric Treatment: A Thematic Analysis

Integrating static and modifiable risk factors in violence risk assessment for forensic psychiatric patients: a feasibility study of FoVOx

INTRODUCTION

Risk assessment is integral to forensic psychiatry. Previous work has highlighted the benefits of using scalable and evidence-based actuarial risk tools developed within forensic populations, such as the online Forensic Psychiatry and Violence Oxford (FoVOx) violence risk assessment tool. We examined the feasibility of using FoVOx in a Swedish forensic cohort and tested whether adding modifiable (dynamic) factors would increase its useability to clinicians.

METHODS

We completed FoVOx assessments on all patients discharged from forensic psychiatric hospitals in Stockholm County, Sweden, between 2012 and 2017 and investigated recidivism rates. In addition, interviews were conducted with the clinicians responsible for each patient on the perceived accuracy, usefulness, and impact of FoVOx, which was examined using thematic analysis.

RESULTS

Ninety-five discharges from forensic psychiatric hospitals were followed up. The median FoVOx score was a 7% likelihood of violent reoffending in two years after discharge. Six discharged patients (6%) were confirmed as violent recidivists using official records with a similar distribution of FoVOx risk categories as the rest of the sample. FoVOx was considered accurate by clinicians in more than half of cases, who suggested that modifiable risk factors could be added to increase acceptability. All clinicians thought that FoVOx was useful, and in 20% of discharges, it would have materially altered patient care. Overall, FoVOx was thought to impact decision-making and risk management, was practical to use, and could be completed without reference to written case material.

CONCLUSION

Completing FoVOx in forensic psychiatric hospitals can complement current approaches to clinical decision-making on violence risk assessment and management.

Factors Affecting Treatment Regress and Progress in Forensic Psychiatry: A Thematic Analysis

International variability and shifting trends in forensic psychiatry lead to gaps in national service provision and needs for service development. This study explores these needs through the subjective narratives of those involved in Finnish forensic services, either as forensic psychiatric patients, their parents, or service providers. Data was gathered by means of thematic interview and subjected to thematic analysis. Three main themes emerged: (1) pre-treatment challenges, (2) institutional/treatment-related concerns about therapeutic security and (3) adapting and recovery. The research highlights the need to develop forensic psychiatric services at three levels. First, it calls for increased risk awareness and risk assessment skills at the general psychiatric level. Second, it emphasizes the need for increased therapeutic engagement throughout the rehabilitative process. Third, it calls for structured and meaningful post-discharge aftercare. At all three levels, gradated security-aware standardization and patient triage in forensic services would help to develop and maintain an intact care pathway. This would decrease offending, marginalization, and suffering. Only then can we begin to meet the requirements of the WHO European Mental Health Action Plan. These findings can contribute to the development of international, standardized treatment models for clinical forensic psychiatric practices.

Forensic Mental Health Nurses' Perceptions of Clinical Supervision: A Qualitative Descriptive Study

Mental health nursing in the forensic services is perceived as stressful as there is often a tension between therapeutic and custodial processes. Clinical supervision has been discussed as a support strategy for nurses. The aim of this paper is to explore forensic mental health nurses understanding of clinical supervision and their perception of its utility within their practice. A qualitative descriptive method was used and 10 mental health nurses were interviewed with the aid of an interview guide. Qualitative data was analysed using a thematic approach culminating in the emergence of three themes.Participants talked about the tension between caring and custodial roles within the forensic services which was stressful and created difficulties in the maintenance of a therapeutic relationship. Clinical supervision was seen as a necessary support to assist nurses working in the forensic services. The findings support the premise that there is a tension between therapeutic and custodial practices. Acknowledgement of the complexities of working within the forensic services and the provision of clinical supervision within a confidential, non-judgemental relationship may assist nurses in the provision of care and the maintenance of therapeutic relationships.

Offender Recovery. Forensic Patient Perspectives on Long-Term Personal Recovery Processes

Knowledge on user experiences from mentally disordered offenders (MDOs) is still limited in a Danish context, especially regarding recovery from offences, severe mental illness, long-term admissions and often involuntarily contact with hospital psychiatry. The study is based on 34 semi-structured interviews with nine forensic patients exploring their experiences with personal recovery processes. The MDOs point out a significant number of elements and factors enhancing, supporting and limiting personal recovery processes. Long-term recovery processes for MDOs involve coming to terms with mental disorders as well as offences. Working with offender recovery implies addressing and understanding the index offence leading to psychiatric measurement as well as addressing risk and prevention of future crime. This coming to terms is an individual and deeply personal process and it often involves several and changing narratives. According to the informants, professionals play a crucial role in supporting recovery processes and maintaining hope and optimism over time. MDOs experience structural barriers limiting recovery potential, especially stigma or limited areas of participation. It is important not to focus solely on personal recovery as a one-dimensional individual process or responsibility, but as a process also marked by structural and organisational challenges.