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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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: Jack Tomlin will visit the Pompestichting and the EFP in the Netherlands

The concept of ‘restrictiveness’ in the forensic psychiatric care setting is often vague. When brought up in conversation, it is not unusual for speakers to inquire further as to what it exactly means. One key aim of this STSM is to visit the Netherlands to ask different interested groups what they thought ‘restrictiveness’ means. Does it refer to the physical confines within which patients reside? The limitations imposed upon them as regards hobbies, personal affects, relationships etc. These questions will be asked of similar individuals in the UK, to further conceptualize ‘restrictiveness’, and to see how or if definitions differ.

A second key aim of this STSM is to better understand the legal framework that surrounds the forensic psychiatric care setting in the Netherlands – again, to compare with the UK. Most of this information was received during my trip to the Expertisecentrum Forensische Psychiatrie.

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