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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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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Restrictiveness in long-term forensic psychiatric care – report of a STSM in the Netherlands

Written by Jack Tomlin – PhD student at Nottingham University

This STSM was undertaken with the aim of developing over the coming years a tool to measure restrictiveness in (long-term) forensic psychiatric care. In December of 2015, I was fortunate enough to receive COST Action funding to undertake an STSM in the Netherlands and I welcomed gladly the opportunity to visit several Dutch forensic institutions and the Expertisecentrum Forensische Psychiatrie.

The ‘Dutch approach’ seems to have become quite en mode in discussions of forensic psychiatric care in the UK. I recently attended an end of project conference on Long-term forensic psychiatric care (LFPC) wherein comparisons of British and Dutch secure settings provoked fruitful discussion. Typically, the Dutch are seen as being less restrictive, more liberal and QoL-focused in their care approach than the British. This is evidenced most strongly in patients’ rights of sexual expression. In the UK, although not codified in any national policy, sexual relationships between patients are prohibited – in the Netherlands, this is not the case. Indeed, a week prior to my arrival in December, two individuals; one from a secure care ward in Nijmegen, another from the long-stay centre in Zeeland, wed in the latter’s chapel.

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STSM – Training of professionals in forensic systems under renovation

Written by Luca Castelletti (Medical Director, REMS Carlo Poma Mantova, Italy)

The whole Italian forensic sector is undergoing a radical process of renovation, as since 1st of april 2015 the 6 national forensic hospital have been closed down and are going to be replaced by small regional 20 bedded-units named REMS standing for Residencies for the Application of  Security Measures. As the process is delegated to the 20 regional health systems, the institution of the residencies is at different speed of building up. In our contest, in the Lombardy region, with a catchment area of around 10 milion people including Milan area, the project is to refurbish and renovate the “old” Ospedale Psichiatrico Giudiziario (OPGs) into a system of 6 REMS for a total of 120 beds. In the regional and central political plans it’s going to be the main forensic centre serving the Country. At the moment we host around 180 patients, of whom 45 are women, as we supply the momentary lack of ready residencies of some other regions.

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Strengths and weaknesses in mental health and legal systems in the European Union: An evaluation

Written by Caty Connel (Senior Forensic Occupational Therapist, Birmingham and Solihull Mental Health NHS Foundation Trust, United Kingdom)

This blog summarises the findings from a study to evaluate the strengths and weaknesses of legal and mental health systems in the European Union.

Aim
To identify which external factors impact on length of stay in forensic mental health services.

Method
Representatives with expertise in long-term forensic care from 16 European countries reported the strengths and weaknesses of the mental health and legal systems in their respective countries. Thematic analysis [1] of the data was conducted for strengths and weaknesses independently, then overarching themes were identified by combining these analyses.

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A STSM comparing patients and services in long term forensic psychiatry in Germany (Vitos-Haina) & Ireland (Dundrum, Dublin).

Written by Padraic O’ Flynn (Senior Occupational Therapist, Central Mental Hospital, Dundrum, Ireland).  

This short term scientific mission explored two forensic psychiatric services in Ireland (Central Mental Hospital, Dundrum, NFMHS) and Germany (Vitos Haina) which cater for long term forensic psychiatric patients. The completed report detailed the overall model and design of the two services, the patient characteristics (diagnosis, average length of stay, index offence, “step”, nationality, IQ)  on long stay wards,  procedures in both services for identifying patient need for psychosocial treatment, comparisons of what psychosocial interventions are offered on long stay units/ with long stay patients, and finally comparisons on quality of life from self reported measures on long stay wards in Ireland and Germany. The report also detailed recommendations for future research in this area. Below the points from the main report are summarised with graphs and diagrams included. Further exploration of comparisons of descriptive characteristics, service models etc. are available in the full report.

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STSM of Mareike Eckert in Central Mental Hospital Dundrum in Dublin, Ireland

Written by Mareike Eckert, MSc,
Junior Researcher of the Pompe Foundation, the Netherlands

In May 2015 I completed a short term scientific mission (STSM) of one week to the Central Mental Hospital Dundrum in Dublin, Ireland in the context of the COST Action IS1302, working group 1: Determination of patient characteristics. The purpose of my stay was to explore, understand and compare factors affecting length of stay in a forensic population in the Netherlands and Ireland using the DUNDRUM toolkit and also a questionnaire about patient characteristics. Factors such as basic demographic information, length of stay, offending and psychiatric history, security and urgency needs, program completion and patient recovery were therefore assessed prior to the STSM including about 60 non-long term patients from different wards in the Pompe clinic in Nijmegen and about 60 long term patients, admitted to the long term forensic psychiatric care unit in Zeeland. Throughout my STSM I gained insight into how the DUNDRUM toolkit is used in practice in the Central Mental Hospital in Dublin. This was an important aspect of my STSM in order to fully understand how to use the toolkit in the research project.

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Call for STSM’s 2015

SHORT TERM SCIENTIFIC MISSIONS 2015

6 STSM’s will be granted in 2015, 3 of them will be related to the topics of the Working Groups and 3 of them will be open.

  • 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 15/02/2015. The STSM must take place before the end of this Grant Period (November 2015).

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

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Approved STSM´s 2014

We´d like to congratulate the following professionals with the approval of their STSM´s:

Ms. Emily Talbot (MSc Forensic Psychology – UK) will visit the Pompefoundation (NL) from 28/08/2014-11/09/2014.

Exploring similarities and differences of long stay patients in the UK & the Netherlands
Mission summary: The overall objective of this STSM is to understand, explore and compare patient characteristics of long stay patients in the Netherlands with those obtained during a UK project. Comparisons will consider similarities and differences between UK and Dutch information; this will include basic demographic information, length of stay, offending and psychiatric history, amongst other information.

In the Netherlands there is a national database of all forensic patients within the TBS system. This allows clinicians to access certain information to monitor their own caseload and performance and also serves to inform national strategy for the development of forensic services. No such resource is available in the UK. The Netherlands have also begun to pilot a specific data tool for long stay patients. In this process collaboration with the forensic research group in Nottingham, UK, has already taken place.

During this STSM I will compare data fields in the Dutch data collection tool with information collected in the UK long-stay study, with a view of assessing how information can be compared. The actual comparison will be conducted once all the data has been collected nationally. This will enable us to identify similarities and differences between the characteristics of long stay patients in the UK and the Netherlands. This STSM will therefore link to the COST working group 1: Determination of patient characteristics. This work will serve to enhance our understanding of long stay patients within Europe and completion of this work would provide the basis for a scientific paper.

 

Dr. Ronan Mullany (MB BAO MCh.; Degree in Medicine – IE) will visit the Pompefoundation (NL) from 01/09/2014-12/09/2014.

Assessing patient characteristics and best practice in LFPC
Mission summary
: To visit Forensic Mental Healthcare settings in the Netherlands so as to investigate which routine assessment instruments used to rate the required levels of physical, procedural and therapeutic security for long term forensic psychiatric patients might be suited for standardised use within other settings and jurisdictions to ensure that patients with similar needs are described when forming advice that can be used for service optimization in multiple sites across Europe.

 

Dr. Mary Davoren (MB BCh BAO; Degree in Medicine – IE) will visit the Pompefoundation (NL) from 01/09/2014-12/09/2014.

Factors Affecting Length of Stay in a Forensic Population in the Netherlands
Mission summary: To examine factors affecting length of stay in a forensic population in the Netherlands using the DUNDRUM-1 Triage Security, the DUNDRUM-3 programme completion and the DUNDRUM-4 recovery scales.

To examine the properties of other forensic needs assessment instruments such as the HoNOS-SECURE and SNAP.

To examine similarities and differences between factors affecting length of stay in forensic populations between the Netherlands and the Republic of Ireland.

 

Dr. Vivek Furtado (CCT – Forensic Psychiatry, General Medical Council – UK) will visit Vitos Klinik für Forensische Psychiatrie Haina (DE) from 12/09/2014-22/09/2014.

Best Practice – Long-Term Forensic Care in Germany
Mission summary
: Germany is one of a few European countries that have specific strategies to deal with long stay patients in forensic psychiatric care. Data obtained from both parts of the STSM will contribute directly to the work of the COST Action:

For WG1: collect demographic and other patient characteristics for those in the long stay service.

For WG2: collect information about practice currently used in managing and treating those individuals who are long-stayers.

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