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

By JackTomlin, PeterBartlett & BirgitVöllm

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.

For full text article, please click here.

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TRAINING SCHOOL 2017 – Vilnius, Lithuania – 11-13 January 2017

Written by Inga Markiewicz (law assistant and psychologist at the Department of Forensic Psychiatry, Institute of Psychiatry and Neurology in Warsaw, Poland)

The main topic of the COST Training School (TS) in Vilnius was: Treatment pathways and aftercare for forensic psychiatric patients. At the Vilnius University, in a very welcoming atmosphere, we were exchanging scientific opinions and practical experiences gathered when working with the forensic patients. The representatives of four member states (Lithuania, Poland, The Netherlands and UK) participated in the above-mentioned event.

Overall logistics was provided by our Lithuanian hosts / the Lithuanian’s COST Action representatives – Ass. Prof. Ilona Cesniene and Prof. Arunas Germanavicius, while the scientific programme was lead by two members of the Core Group of the COST Action 1302 – Mr. Peter Braun and Dr. Erik Bulten.


The TS consisted of lectures, workshops and self-study. The participants had an opportunity to listen to presentations about the theory of ‘recovery’ and the Good Lives Model in the context of Risk Needs Responsibility – principles of forensic psychiatric care.

Taking into account that different countries have different good points and weaknesses in their forensic systems, TS participants characterized the models of forensic psychiatric care in their countries. All good and bad solutions of the systems were analysed in relation to the regulations and common practice, both at the stage of ‘pre-trial’, and the process of diagnosis, as well as detailed studies, risk assessment, comprehensive treatment (bio-psycho-social model), aftercare and discharge aspects.

All contributors of the TS agreed that treatment process and aftercare must involve jurisdictions and legal frameworks to make satisfactory progress within the system and/or in aftercare.

These multi-dimensional analyses and comparisons of various solutions in the system of forensic psychiatry in Lithuania, Poland, England and the Netherlands were used to develop a joint model that can offer guidelines for forensic psychiatry for all European countries. The initial ideas have been put into tables (Table 1) and all participants have been working on them.

Vilnius Table 1

Vilnius Table 1a


The ideas and results of our work during the TS in Vilnius should materialize in a paper with recommendations on best practice in treatment and aftercare in forensic psychiatry (the universal model),

based on the SWOT analysis of the systematic best solutions practiced in individual countries. We started editing the common text during TS and now its final version is being prepared.

The TS in Vilnius was very well organized, broadening our knowledge about forensic systems, treatment and aftercare in different EU countries.

During our TS we had an opportunity to visit the Vilnius City Mental Health Centre, where we saw the facilities and talked with the staff and patients. We all found that field trip very interesting.

20170112_Vilnius5  20170112_Vilnius4

Our local organizers also remembered about intellectual, historical, cultural and social activities during TS. We took part in a planned guided tour, visiting many historical places (e.g. Vilnius University Library and Palace of the Grand Dukes of Lithuania) and greatly enjoying excellent national food.

At the end, I would like to thank COST Action IS 1302 and all participants of the TS in Vilnius for providing me with better knowledge, a broader view at the quality of forensic psychiatric care, a number of ideas and solutions that I could draw from the systems of other countries, also for the opportunity to exchange experiences, listen to valuable comments and to take part in constructive discussions in a pleasant working atmosphere.

All in all, the TS in Vilnius has been a very enriching experience.


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Living in a forensic-psychiatric institution as a life perspective? – Quality of life and needs of long-term forensic psychiatric patients

Written by: Martin Feißt, Sabrina Wiecek, Bernd Dimmek and Inga Markiewicz

Across Europe an increase in the duration of the placement of patients in theforensic hospital can be observedas well as in GermanyThis development makes it imperative to deal with this topic and the related legalsocial and ethical issues. A cooperation between the LWL Academy of Forensic Psychiatrythe University of Witten/Herdecke and the Institute for Psychiatry and Neurology in Warschau, Poland,  an educational research project on quality of life of long-term patients in forensic hospital” has been taking place (up to and including the winter semester 2015/16).

The aim of this project is to attain a better understanding of the needs of patients on the basis of qualitative interviews with patients and staffwhich may be important for the design of the accommodation and for therapeutic purposes.


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Training School 2016 Helsinki 21–23th September

Written by Mika Rautanen (M.D. specialising in forensic psychiatry, Helsinki University, Finland)

The COST Training School was comprised of two workshop days for selected participants and a general lecture day in the middle targeted for everyone interested in how modern forensic facilities should be designed today. Altogether, there were well over 70 professionals representing medical, psychological, nursing, juridical and architectural fields of expertise from various European countries.

A fruitful and open discussion was set as the leading principle through the Training School by Dr. Allan Seppänen, clinical director at Helsinki University Hospital and Finland’s COST- Action representative. He kept the content of the program open in the sense that instead of tight schedules we had time to tackle and discuss real-life problems presented by the trainers and us trainees. Due to great interest in participating, the lectures had to be moved to a larger venue which proved to be a necessary solution for the workgroup days too. Facilities and catering were just right for our purposes.


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Speakers List Training School 2017 – Treatment pathways and aftercare for forensic psychiatric patients

Peter Braun (MSc) – Peter C. (Conrad) Braun is working as a psychologist and psychotherapist in the forensic psychiatric field in the Netherlands since 1979. After completing training as psychologist het worked in the State Mental Hospital (R.P.I.) in Eindhoven for 21 years. He worked mainly with TBS patients with psychotic disorders, personality disorders and addiction problems. During this work he completed his training as a psychodynamic psychotherapist and worked also in several outpatient mental health organisations as psychotherapist.

Part of his training as a behavioural therapist, he followed in Belgium (Leuven and Antwerp). From 2000 – 2006 he worked as Head of treatment in a TBS clinic in Venray (De Rooyse Wissel) where he worked mainly on a admission ward and a resocialisation ward. In 2006 he was accepted to lead the longstay facilities of the Pompefoundation (Nijmegen) to set up a new facility in the village of Zeeland, where he is still working now.

Besides these activities Peter had a training to evaluate persons for the Court and to evaluate the psychological situation and level of responsibility. He is registered as expert witness for the courts (NRGD).

Peter has a great interest in long-term forensic psychiatric care. Since some years he is chair of a Special Interest Group on Long-term Forensic Psychiatric Care (LFPC) of the International Association for Forensic Mental Health Services (IAFMHS). Since 2013 he is chair of the EU funded COST-Action IS1302 which was applied for by Dr. Erik Bulten (Pompefoundation) on behalf of the Pompefoundation and several other international institutes (Nottingham University, Prof Dr. B. Völlm). Creating a Research Network on Long-term Forensic Psychiatric Care is the main aim of this initiative.

Peter published a few articles on long-term forensic psychiatric care as co-author. He also wrote a chapter in an edited book on clinical milieus in forensic psychiatric care

Erik Bulten (PhD) – Dr. Bulten is Head of Assessment, Research and Professional Development at The Pompefoundation (Institute for in- and outpatient Forensic Psychiatry. Dr. Bulten, therefore, contributes both academic and practitioner expertise to the Social Climate Research Network. He is experienced in doing research in clinical practice. As Head of the research department of the Pompeoundation he is for instance involved in studies on quality of life, risk assessment, social climate, substance abuse, neurocognitive research, patient characteristics and determinants of long stay patients. Erik Bulten is connected to the Behavioural Science Institute, Radboud University, Nijmegen. Erik was author or co-author of more than 100 articles or chapters. As a clinician and head of his team Dr. Bulten is member of the board of managers and involved in developing a effective, safe and therapeutic environment for the treatment of patients and the developing of effective treatment interventions and treatment pathways. Erik is the scientific advisor of the Cost Action.

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Timetable Training School 2017 – Treatment pathways and aftercare for forensic psychiatric patients


Time/Location Vilnius Vilnius Vilnius
9.00-9.30 Welcome/introduction(Ilona Čėsnienė, Arūnas Germanavičius)
9.30-10.30 Introduction of COST IS1302, Introduction of participants, Organisational issues and Outcome expectations from the participantsPRESENTATION

(Peter Braun)

Identifying best practice, conclusions drawn from SWOT Analysis & Short Evaluation of the literaturePRESENTATION

(Erik Bulten)


Second writing blockSELF STUDY

(Peter Braun, Erik Bulten)

10.30-11.00 Coffee Break Coffee Break Coffee Break
11.00-12.30 Theory of Recovery, Good Lives Model and their integration into Risk-Needs-Responsivity principlesPRESENTATION

(Erik Bulten)

Outline of the report based on literature & SWOTs followed by first writing blockWORKSHOP / SELF STUDY

(Peter Braun, Erik Bulten)

Presentation of results of second writing blockWORKSHOP

(Peter Braun, Erik Bulten)

12.30-14.00 Lunch Lunch Lunch
14.00-15.30 Preparation of country specific SWOT Analysis of treatment pathways and aftercareSELF STUDY

(Peter Braun, Erik Bulten)

Continuation of first writing blockSELF STUDY

(Peter Braun, Erik Bulten)

Evaluation, conclusions and decisions on how to progress ?what?WORKSHOP

(Peter Braun, Erik Bulten)

15.30-18.00 Presentation of SWOT Analysis, followed by analysis and discussion on SWOT AnalysesWORKSHOP

(Peter Braun, Erik Bulten)

Presentation of first results, discussion of special issues and first conclusionsWORKSHOP

(Peter Braun, Erik Bulten)

  Social event Dinner  

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Training School 2017 – Treatment pathways and aftercare for forensic psychiatric patients

What is the training school about?

Forensic patients can get stuck in the system due to patient characteristics, quality of treatment but also the quality and availability of facilities with a lower level of security and/or aftercare. The focus will be on the quality and availability of facilities with a lower level of security and/or aftercare, the transitions between systems and the boundaries and problems of these transitions will be connected to the aims of the Action.

Models of aftercare will be discussed. The mechanisms behind pathways and aftercare will be analysed. The theory of ‘recovery’ and the ‘Good Lives Model’ approach will be presented and connected to the aim of this training school; both models will be integrated in the Risk Needs Responsivity-principles of forensic psychiatric care.

Different countries will have different strengths and weaknesses in their treatment pathways and aftercare. Based on specific SWOT analysis of the system characteristics of the participating countries, a guided discussion will result in specific issues, opportunities, best practices, legislation and threats on the patient’s progress through the specific stages of treatment and aftercare.


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