“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

Clinical Psychologists’ Talk About Inpatient Service Users’ Sexual Expression and Its Implications on Restrictive Practice: A Foucauldian Discourse Analysis

Background Sexual expression is restricted in psychiatric inpatient settings, supported by a riskfocused body of literature, often produced by medical professionals. Little research has been conducted into the nature of clinical psychologists’ views, influences, and roles. Aims This study sought to understand how clinical psychologists talk about inpatient service users’ sexual expression and its impact on restrictive practice. Several subquestions were developed: - How do clinical psychologists construct inpatient service users’ sexual expression? - What discourses influence clinical psychologists’ talk about inpatient service users’ sexual expression? - How do clinical psychologists describe their roles and responsibilities in relation to inpatient service users’ sexual expression, and how does this relate to restrictive practice? Method To contrast with literature characterised by quantitative studies, a social constructionist qualitative approach was taken, using semi-structured interviews conducted with 15 UK clinical psychologists. Foucauldian Discourse Analysis (FDA) highlighted constructions, roles and responsibilities, and the influence of wider discourses. Findings The clinical psychologists constructed inpatient service users’ sexual expression as being risky, pathological, conflicting with social norms, useful for recovery, and a part of being human. These constructions allowed the participants to adopt roles as protectors, diagnostic experts, and moral governors, which tended to support restrictive practice, and pseudo-occupational therapists and advocates, which tended to resist restrictive practice. Discussion By using FDA, it has revealed systemic, intra-team, and social power dynamics in relation to sexual expression and restrictive practice. These findings are used to suggest new approaches to research and practice. Conclusion The clinical psychologists’ talk was nuanced, reflecting their thought and care, and the difficulties of resistant practice within a medicalised setting. They are subject to the disciplinary structures of the hospital and consequently recreate medicalised and risk-focused discourses which support restrictive practice. However, they also use discourses which have been under-represented in the literature and resist this

Exploring patients’ experiences of the staff-patient relationship and staff experience of compassion satisfaction in forensic settings using thematic synthesis and interpretative phenomenological analysis: a portfolio thesis

This thesis is submitted in partial fulfilment of the requirements of the Doctorate in Clinical Psychology. The thesis is comprised of two journal articles exploring patient and staff experiences of forensic mental health. The first journal article is a systematic review collating and synthesising prior research around how forensic patients experience the staff-patient relationship in forensic settings. The quality of included studies is also critically appraised. Thematic analysis is used to synthesise results across studies. The results shed light on both the positive and negative patient experiences of this relationship as well as what patients feel are the implications for patient recovery. Avenues for future research and application to practice are discussed. The second journal uses Interpretative Phenomenological Analysis to explore staff experience of compassion satisfaction in a forensic setting. Seven forensic mental health professionals were interviewed using a semi-structured interview schedule. Group experiential themes highlighting convergence and divergence across participants’ lived experiences are discussed. Participants shared experiences of both achieving a sense of compassion satisfaction as well as having such satisfaction impeded. There are also themes around the personal cost of this work. Again, the implications for future research and applications for practice are outlined

Coercive bullying among forensic inpatients: How do individual and environmental factors contribute?

Coercive bullying is a type of aggression where an individual puts pressure onto a peer to engage in (or not retaliate to) a specific behaviour that they do not want to do. Though a previous study found 36% of forensic inpatients were victimized by coercive bullying in the previous month (Cooper et al., 2011), there has been little done in the literature beyond establishing prevalence. The purpose of the current line of research was to: 1) develop an expert-derived list of coercive bullying behaviours, 2) establish the prevalence and nature of coercive bullying, 3) develop a preliminary understanding of the individual and environmental factors associated with perpetration and victimization, and 4) understand the motivations for engaging in coercive bullying in a forensic inpatient setting. This was achieved through two complementary studies: Study 1 was a qualitative investigation with 12 frontline forensic inpatient staff and Study 2 was a mixed-methods study with 94 forensic inpatients living across four secure hospitals in Ontario, Canada. Study 1 resulted in an 18-item coercive bullying behavioural checklist for use with the subsequent patient sample. The staff sample were very homogenous with their perceptions about the individual and environmental factors associated with perpetration and victimization. In Study 2, 73.4% and 37.2% disclosed coercive bullying victimization and perpetration in the previous three months, respectively. The most common types of behaviours reported were related to the acquisition of resources (e.g., a peer pressuring another peer for money, cigarettes, food). Relationships between the individual and coercive bullying perpetration (e.g., traits of psychopathy) and victimization (e.g., mental illness symptoms) were established, with effects ranging from small to large. There was less support for measured environmental antecedents, but qualitative results highlighted their importance nonetheless. The most important environmental factors appear to be deprivation and discrepancy of resources, and staff supervision. The results highlight the clinical significance of a staff- and patient-acknowledged, pervasive and problematic phenomenon occurring in secure forensic hospitals. The dissertation lays a much-needed foundation in the scientific literature on a relatively unstudied topic, and discusses implications and suggestions for future research

Risk Assessments in Forensic Psychiatry: Consequences and Experiences for Patients and Nurses

In forensic psychiatry, risk assessment of future violence poses a great challenge to mental health care professionals. Forensic psychiatric patients are particularly vulnerable due to their complex mental health needs in combination with criminal behavior. The overall aim was to evaluate the importance and validity of risk assessments in forensic psychiatric care, and the related experiences of patients and nurses. The methods used were, (I) statistical analyses of file register data, (II) focus group interviews with nurses, (III) semi-structured interviews with inpatients, and (IV) quantitative analyses of assessments based on forensic psychiatric investigations. Findings: From a cohort of 125 forensic psychiatric inpatients, the findings showed a median length of stay of slightly more than two and a half years, predicted by previous contact with child- and adolescent psychiatry, violent index crime, psychotic disorders, history of substance use, and absconding during treatment. Treatment with special court supervision resulted in an almost five times longer length of stay compared to treatment without such supervision. Sixty percent were involved in at least one adverse event during their treatment. Elements of person-centered care were identified when nurses’ views were explored. Great efforts were made to confirm the unique person behind the patient, even when challenged by patients’ previous violence. Relationships with patients were considered crucial for successful risk management, this needed to be balanced against caring and restricting actions. The patients’ experiences of risk assessments could be summarized in three categories; taking responsibility for one’s own situation, taking charge of the present, and being involved and having impact. To evaluate the utility of the SAPROF (Structured Assessment of Protective Factors for violence risk), predictive validity was compared to three risk- and strength-based instruments: SAPROF, HCR-20 (Historical Clinical Risk Management-20), and LHA (Life History of Aggression). Only the SAPROF subscale ‘internal factors’ and the LHA total score, showed a significant, but weak, predictive ability of the occurrence of violent incidents. Conclusion: Perceived risk of future violence, as determined by the court, determined length of stay in forensic psychiatric care much more than clinical needs. However, structured instrument for risk assessments, currently used by clinician, showed poor ability to predict violence during inpatient care. Nurses in forensic psychiatric care found that risk assessments offered opportunities to confirm the patient as a person and to establish a trusting relationship. The findings point to the importance of promoting agency and active participation in the patients’ own care processes, highlighting the most important conditions for autonomy and well-being

Relating Following Aggression - Women's Medium Secure Services

Background: Women in medium secure services can present with aggressive behaviours and a high level of risk to self and others. Research suggests frontline staff are frequently the victims of, or witness to aggression by forensic inpatients. The therapeutic relationship is proposed as central to therapeutic outcome, but may be jeopardised by inpatient aggression. Staff perceptions of the therapeutic relationship and aggression have not been explored in women’s medium secure services. The study aimed to develop a theoretical model grounded in frontline staff perceptions of the therapeutic alliance and aggression in a women’s medium secure services. Method: The data from 13 semi-structured interviews conducted with frontline staff was analysed using Constructivist Grounded Theory methods. Results: The tentative descriptive theoretical model “Relating Following Aggression” emerged from the interview data. Contextual information supports five core categories, and the related sub-categories. The findings propose the therapeutic relationship is intrinsically linked to boundaries, and boundary violations could result in relational deterioration. Aggression affected the emotional and psychological wellbeing of the participants, and compromised the staff-patient relationship. The participants were fearful of aggression occurring in their workplace which resulted in them spending less time with the women and withdrawing from the therapeutic relationship. Conclusion: The findings reveal the complexity of the frontline staff-patient relationship in women’s services. Aggression occurring between frontline staff and women can seriously compromise the therapeutic relationship through a crossing of the boundary line and a perceived breach of trust. Greater support for both the frontline staff and women is required. Future research is recommended. Keywords: Frontline staff, women, aggression, forensic, therapeutic relationship, Constructivist Grounded Theory

Identifying risk and protective factors in conditional release/discharge using systematic review and exploring lived experiences of compulsion and restriction orders using interpretative phenomenological analysis: a portfolio thesis in forensic mental health

Compulsory treatment presents an ethical quandary and thus far research provides little promise regarding reduced readmission or length of inpatient stays, though some value has been shown in administering outpatient treatment. Those in forensic services and particularly those under restriction orders face the greatest constraints on their liberty with detention imposed “without limit of time”, unlike time-limited sentences in the prison system. There is a dearth of research exploring patients perspectives of compulsory treatment and particularly the most restrictive forms of this. The current study used interpretative phenomenological analysis to analyse interviews with participants about their experiences of living under restriction. Results derived four superordinate themes; (1) How did I end up here? (2) Impact: Power, Punishment and Protection (3) Surviving and Adapting (4) Healing. The results are reviewed in the context of extant findings; clinical implications and areas of future research are discussed. Conditional release (CR) is the primary mechanism for managing individuals under forensic care in the community. Services must identify those at higher risk for revocation/ readmission (RR) and promote protective factors for increased quality of life and to minimize recidivism. A systematic search was conducted to identify, summarise and critically assess studies that have evaluated factors associated with RR in forensic patients. The review found that higher substance use, personality disorder/ traits, severity and chronicity in psychiatric illness, criminality and minority ethnicity are risk factors for RR. Protective factors identified were: white ethnicity, being married, social security, not having personality disorder, longer tenure in outpatient programme, clozapine treatment, fewer incidents while on CR, labour skills and higher functioning at CR. Future research should include prospective study designs, standardised measures, and variables independent from RR. Clinical implications include identification of individuals with risk factors for RR and promotion of protective factors

Developing a person centred low secure model of care for forensic populations in NSW

Systems to support individualised care and treatment of forensic mental health patients have not been a priority in Australasia when compared to more well-developed systems in the UK and Canada. Despite the available legislative provisions in Australia, the mentally ill offender population in New South Wales (NSW) is often not supported with accommodation appropriate for the levels of restriction they need as they move towards community re-entry. A significant number of patients within the NSW forensic mental health system continue to be accommodated in unnecessarily high security facilities due to a lack of low-secure facilities and supported community placements, even though the National Disability Insurance Scheme (NDIS) and programs such as Housing and Accommodation Support Initiative (HASI+) have improved provision of this in recent years. This study thematically analyses interviews with clinical experts working in forensic mental health in NSW to conceptualise a new model of care to appropriately support people with mental illness who require low-secure forensic mental health services, and to consider how such a model could be implemented. Semi-structured interviews were conducted in two phases. The first phase involved 23 purposively selected experienced forensic mental health clinicians - primarily nurses, doctors, psychologists, social workers, occupational therapists and administrators - with interest, knowledge, and experience in forensic mental health services to gain insight into issues with the current system and relevant components of a new model for low-secure forensic care in NSW

Navigating internalized stigma and identity development in bipolar disorder I: A grounded theory investigation.

Mental illness stigma occurs at multiple levels in Western societies. Internalized stigma, the application of negative stereotypes and prejudice about mental illness to self-concept, has deleterious effects on mental health for adults living with a serious mental illness. Historically, research on stigma in serious mental illness has centered on schizophrenia. Recently, researchers and clinicians have drawn attention to bipolar disorder I, an affective disorder that creates disruptions in functioning and increased risk for substance abuse and suicide. Despite the growing literature establishing the relationship between recovery in serious mental illness and identity, little is known about how adults in long-term recovery from bipolar I manage experiences of internalized stigma. Additionally, few qualitative studies have examined how lived experiences of internalized stigma may affect recovery in bipolar I disorder. This study aimed to understand how lived experiences of internalized stigma influenced identity and recovery processes in bipolar disorder I. Charmaz’s constructivist grounded theory methodology was used to create a novel theory about how individuals navigated a diagnosis of bipolar I, internalized stigma, and the recovery process. Semi-structured interviews were conducted in-person and via video conferencing with a sample of 13 adults undergoing current treatment for bipolar I. The data yielded seven themes related to navigation of the bipolar diagnosis, symptoms, and internalized stigma. Findings revealed that identity development occurred while participants reconciled internalized stigma with understanding of self in relation to bipolar disorder. This reconciliation process and identity development involved negotiation with family members and romantic partners. Throughout the recovery process, participants drew from gifts of bipolar disorder and acquired strengths that fostered self-acceptance and embracing of a transformed, unified identity