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.

Findings - External factors influencing forensic mental health services
There was broad consensus internationally about which factors are considered desirable and which limit forensic mental health services and thus impact adversely on treatment and length of stay.  Where desirable factors were present these were reported as strengths and where absent they were recognised as weaknesses.  For example countries where there was a commitment to investment in forensic services recognised adequate funding as a strength, whereas countries whose population and government did not value or invest in mental health or forensic services reported funding as a weakness.

Analysis of data gathered demonstrates that the strengths and weaknesses in mental health and legal systems in Europe are described according to six themes with further subthemes (Figure one).

Figure 1 - CatyCare pathways
Forensic services should have clear and inclusive admission criteria that reflect the ability of the service to provide care and treatment for admitted patients.

Potential to progress through reducing levels of restriction is a strength when at the forensic services discretion (rather than through court applications or fixed sentences).

Absence of or poor quality forensic out-patient and community services were consistently recognised as a weakness. Active social reintegration provided by specialist rehabilitation professionals was lacking across the pathway in some countries, and particularly limited in the community in almost all countries.  This contributed to delayed discharge, due to concerns about the patients’ risk of relapse and reoffending in a poorly supported community placement.

Resources
A few countries were adequately resourced and supported, but the majority reported deficits in funding, staff quality and numbers, and capacity. When demand outstrips forensic psychiatric services ability to meet the needs of their patients some received inadequate, inappropriate or no treatment that increased length of stay or risk to themselves/others.

Checks and balances
Harmonised criminal, civil and mental health legislation is thought desirable.  External monitoring by independent legal and care ‘watchdogs’ is valued, and systemic management is considered essential. Where the law is weak, not applied or interpreted by poorly trained legal professionals, the impact on forensic services was considered negative.

Stigma and societal ‘blame-culture’ contribute to risk-averse clinical decision making. Social rejection/failure upon discharge was viewed as increasing risk of relapse and reoffending.

Treatment Environment
Hospital, as opposed to prison is thought by the majority to be the most appropriate environment for forensic psychiatric patients. But it must be of sufficient quality, offering multiple interventions in purpose built and modern facilities. There was no consensus regarding urban or rural location.

Independence of forensic psychiatry
All participants felt the expertise required to work with forensic patients needed to be recognised by considering forensic psychiatry as an independent discipline. There was variation in the respect and recognition offered to forensic specialisation by nation.

Sharing expertise
Collaboration between agencies, organisations and professions was desirable.  Particular weaknesses were reported in research collaboration and the need for new talent to train abroad due to a lack of specialist opportunities in some EU countries.

Strengths and limitations
A single participant from each country reported the data.  Most participants were psychiatrists, identified by association with the COST Long-Term Forensic Psychiatric Care Group. There were some participants from other disciplines. A different group of participants, from different professional backgrounds, nations or national regions, may have provided different data.

Data saturation and strong consensus regarding the desirable attributes of mental health and legal systems indicates credibility. However, as a first exploration of this area, the data should be interpreted with caution.

Conclusion
This study identified factors considered to impact on length of stay in forensic mental health services. Further research is required to establish which can be effectively shared across nations to improve outcomes for patients, regardless of their country of residence.

The study was undertaken as part of early career researcher Short-Term Scientific Mission to Finland, funded by COST