The current services, designed to accelerate throughput and providing intensive treatment with a view to rehabilitation back into the community, may not be appropriate for the group of long-term forensic psychiatric patients. However, so far only a few countries have responded proactively to the needs of these offenders. In the Netherlands, e.g. specialized wards on long-term forensic psychiatric care have been developed, which cater for about 10% of the total forensic-psychiatric population. Similarly, Germany has developed special wards in some hospitals although no national policy exists to guide these developments. In the UK the possibilities of implementing specialized long-stay services are explored.
Despite ongoing concerns about the increasing length of stay in highly restrictive forensic-psychiatric settings, research attempting to identify the characteristics and needs of long-stay patients is limited. Clinical experience suggests that the long-stay forensic population is a heterogeneous and complex group, and one service model may not be suited to all these patients. Some have argued that new types of services are required, focusing primarily on quality of life. However, without more knowledge about this population evidence-based service development cannot be achieved. In addition, the ethical and legal challenges of such service development need careful exploration.
The scientific programme of the Action is designed to meet the aim and objectives of the Action: to exchange, enhance and broaden the knowledge on (cost) effective services in long-term forensic psychiatric care. In order to achieve this, the Action focuses on three main core areas:
- Characteristics of long-term forensic psychiatric patients
- Towards best practice in long-term forensic psychiatric care
- Meeting needs and optimizing quality of life in long-term forensic psychiatric care
Each theme is deployed by a Working Group that will resolve the theoretical, methodological and empirical implications within these core areas. The Working Groups comprise of researchers and practitioners from different disciplines and different countries. The 3 Working Groups together offer a comprehensive, interdisciplinary programme of activities that will bring together the extensive, but currently highly fragmented and scattered knowledge and resources on long-term forensic psychiatric care in Europe.
Forensic psychiatric care is aimed at improving mental health care and reduction of risk of recidivism of mentally disordered offenders. The number of forensic beds has increased rapidly in several countries during the last two decades. The duration of treatment is also increasing. Strong societal demands for coercive measures against “dangerous” mentally disordered persons and an increasing focus on reducing risk, as well as reduced funding for aftercare are likely contributory factors for these changes. A significant proportion of mentally disordered offenders may require long-term, potentially life-long, forensic psychiatric care (Reed, 1997; Shaw, Davies & Morey, 2001; Harty et al., 2004; Melzer et al., 2004) although, depending of service provision in the different EU countries, some of them may reside in prison rather than in forensic psychiatric institutions.
A systematic literature review on characteristics of long-term forensic psychiatric patients identified a very limited number of studies. One early study in a high secure hospital in the UK identified severity of index offence as most important factor for personality disordered patients, while for those with a major mental illness psychopathology was a more relevant predictor of duration of stay (Dell, Robertson & Parker, 1987). Factors associated with the pro-longed stay in forensic psychiatric care are treatment history, seriousness of index offence, ‘restriction orders’, and lack of facilities with lower levels of care and security (Brown & Fahy, 2009; Knapp et al., 2007). Besides, clinical practice suggests that poor progress of these patients is caused by complex psychopathology, non-compliance in therapy and/ or learning disabilities.
In the few articles where long-term forensic patients are specifically mentioned, concerns have been expressed about the conceptual void regarding what services should be developed for this particular patient-population and the long-term effects of continuing involuntary treatment (Mason, 1999; Salize, 2005). Long-term inadequate placement of patients within excessively restrictive settings is harmful to these individuals, e.g. through becoming hospitalized. Nevertheless, not all these offenders need these restrictions as studies in the 1990’s and early 2000nds highlighted that between one third and two thirds of forensic patients resident in high secure settings in the UK did not require that level of security (Maden et al., 1993; Reed, 1997; Pierzchniak et al., 1999; Shaw, Davies & Morey, 2001; Harty et al., 2004). In addition, a recent study showed that being a forensic psychiatric patient in itself as well as aggressive behaviours act as obstacles in being redirected toward community-based treatment (Dumont et al., 2012). The authors underline the need to further assess interventions targeting aggressive behaviours to allow a greater number of patients to access community-based care.
‘Need’ in long-term forensic psychiatry has to address a variety of mental and general health problems, as well as aging and psychosocial functioning. Findings from a study in long-term patients in a general psychiatric setting suggest that needs are strongly related to diagnosis and cognitive functioning and that unmet needs are strongly negatively correlated to quality of life (Wiersma & Van Busschbach, 2001). Mentally disordered offenders with an above average length of stay may well require a different type of services. For instance, a study about forensic patients over 55 years of age or residing for longer than 10 years, showed high rates of physical illness, mobility impairment, sensory impairment and poly-pharmacy (Lightbody et al., 2010).
The concept of quality of life has only recently received attention within (long-term) forensic psychiatric care. Some authors stress that in a high secure context, with long-term involuntary liberty deprivation, aspects like autonomy, lack of freedom, sense of control, restriction of movement and constraint of sexual relations will diverge and influence the well-being of patients (Coid, 1993; Mercier & King, 1994). Empirical research in this area has, however, so far been single-centered, decreasing the generalizability of the findings (Swinton, Carlisle, & Oliver, 2001; Van Nieuwenhuizen, Schene, & Koeter, 2002; Saloppé & Pham, 2006). Besides, the instruments used in these studies to assess quality of life are either based on general society or psychiatric patients, ignoring the restrictive context of (long-term) forensic psychiatric care and its’ influence on quality of life (Van Nieuwenhuizen & Nijman, 2009; Swinton, Oliver, & Carlisle, 1999; Walker & Gudjohnson, 2000). Therefore, the conceptualization of quality of life, based on perceptions of patients in long-term forensic psychiatric care, differs from that required for use in (forensic) psychiatric studies (Vorstenbosch et al., 2010).
Systematic comparative research on long-term forensic psychiatric care has been sparse. Apart from the studies already mentioned and some EU research projects on marginally related subjects, few international studies have been conducted in this area. There is a substantial lack of knowledge and international cooperation is needed to deepen the understanding of ‘best practice’ in long-term forensic psychiatry and to address the current lack of indicators to describe and standardize the most basic data in the field e.g. service provision, outcomes and/or prevalence in Europe (Dressing & Salize, 2004; Marušič & Kamin, 2005; Becker & Kilian, 2006; Gordon & Lindqvist, 2007; Salize & Dressing, 2007; WHO, 2008).
Although some research has been conducted to identify factors associated with a long duration of stay, a detailed analysis of the current long-term forensic psychiatric patient population (including comparison with the characteristics of other forensic patients and offenders), determining long-term forensic psychiatric care, treatment pathways and specific long-term needs, is lacking. This Action aims to fill this gap, increase the knowledge on important aspects of long-term forensic psychiatric care and, support the innovation of the services currently provided.