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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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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Client Service Centre – Ex-User Involvement at the “Woenselse Poort” in the Netherlands

The process of recovery is often more difficult for forensic psychiatric clients than for people who are treated within the ‘regular’ mental healthcare system. Within a secure facility such as De Woenselse Poort (‘the Woensel Gateway’), the Client Service Centre was set up with a view to offering clients more support and opportunities. Very soon after admission, the Client Service Centre can be called upon to help clients to help themselves and develop their skills and acquire general knowledge, separate from their treatment program and hospital ward. In this way, the Client Service Centre tries to assist clients in their recovery process.

The complete article – written by Toon Walravens – about the Client Service Centre and ex-User Involvement can be read here.

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Call for Short Term Scientific Missions 2016

4 STSM’s will be granted this period, the aims are related to the topics of the Working Groups:

1. To review the availability of longer stay units and their therapeutic regime in various participating countries. STSM Call 1 2016
2. To review the legal and health system bottlenecks in various participating countries that prevent individuals moving along their care pathway to less restrictive settings. STSM Call 2 2016
3. To collect demographic and clinical data (e.g. diagnosis, age, index offense), and to assess other more objective QoL variables that are related with the subjective experience of QoL such as daily activities, enclosure and/or leave. STSM Call 3 2016
4. To compare the needs as mentioned by patients with the needs assessed in standardized needs instruments such as the CANFOR. STSM Call 4 2016
  • Who? STSM applicants must be engaged in a research programme as a postgraduate student or postdoctoral fellow, or be employed by or affiliated to an institution or legal entity.
  • How? By obtaining a written agreement from the host institution, registering on e-cost and completing the online application form.
  • When? The submission deadline is 31/07/2016. The STSM must take place before the end of this Grant Period (March 2017).

For more detailed information on STSMs click here. For any other questions, you can contact the STSM coordinator Denise van Eeden (dvaneeden@efp.nl).

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Training School 2016 – Modern forensic in-patient facility design standards

What is the training school about?

Forensic psychiatric care is aimed at improving mental health and reducing the risk of recidivism of mentally disordered offenders, within the least restrictive setting possible and with a view to community reintegration, whilst simultaneously maintaining a secure treatment environment. However, the way the services are defined and governed across Europe differ significantly: some countries have issued detailed criteria for different levels of secure care, whereas in other countries security is much more loosely defined and has essentially developed over time along with clinical practices. Also, different historical factors have dictated that in some countries there are secure units that operate in densely populated urban areas, whereas in some countries forensic facilities have been placed further from the surrounding communities.

The rationale behind developing urban forensic services is that this can provide various forms of rehabilitative stimuli not as easily accessible in a more rural environment. However, issues concerning the safety of both the patients themselves and their environment merit particular planning in a more centrally placed location. Drugs, alcohol and antisocial interaction are all factors to take into consideration. A sensitive balance between providing care and security is vital for a well-functioning urban forensic service. Buildings must be used to facilitate the treatment model and care pathway, and to promote community engagement and recovery. Maintaining a high standard in building materials and continually improving the design of the environment will help to improve outcomes for patients. The building should help to ensure comfortable, secure surroundings for patients many of whom are detained for prolonged periods of time.


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