Bridging the gap : patients and professionals perspective on risk and recovery in forensic psychiatry

Background: The aim of forensic psychiatry is to protect society and care for offenders with severe mental illness (SMI). People with severe mental illness show a certain increased risk of committing violent crimes, which is significantly increased by drug use (Elbogen & Johnson, 2009). The mission includes counteracting the risk of relapse into acts of violence and other unwanted outcomes, as well as promoting recovery. The mission can be regarded as double and partly contradictory because restrictive measures can counteract treatment and rehabilitation. In order to fulfil the mission, a systematic approach with scientifically verified tools is needed. There is a need for an increased understanding of how the risk is assessed and what the recovery process looks like in a forensic psychiatric context, in order to bridge the contradictions between these areas of use. Both the patient and staff perspective need to be included in this context.

Aims: The overall aim is to examine what patients and staff in forensic psychiatric care perceive as effective in reducing the risk of relapse into acts of violence and other unwanted outcome. The aim of study I is to describe forensic inpatients' own view on which aspects of care and personal recovery are important in reducing their risk of relapse into acts of violence and other unwanted outcome. The aim of Study II is to examine patients' own views on what are important aspects of personal recovery and its challenges in forensic mental health settings. The aim of Study III is to evaluate how the risk of relapse into acts of violence and other unwanted outcomes for inpatients in forensic psychiatric care are affected by the staff identifying and addressing specific critical factors from the START instrument in their care plans. The aim of Study IV is to test the unidimensionality of the START instrument. If the START instrument is unidimensional, it support the common use of the total sum of strengths or vulnerabilities, as a measure of the risk of relapse into acts of violence and other unwanted outcome.

Methods: Study I is an interview study based on 10 interviews. The interviews were analysed with a qualitative content analysis according to the Graneheim & Lundman (2004) model. Study II is a literature study where 21 included articles from 1229 hits are analysed using Thomas & Harden (2008) three-step model for thematic synthesis. Study III examines 787 START assessments with respect to staff's assessment of the relevant critical factors that reduce the risk of relapse into acts of violence and other unwanted outcome. Matched paired t-tests have been used as a statistical method. Study IV examines 2890 START assessments from forensic psychiatric clinics in Denmark, Finland, United Kingdom and Sweden with regard to the measuring of properties of the instrument. For this purpose Principal Component Analysis, PCA and Cronbach's α is used.

Results: In study I, four themes emerge that patients perceive essential for reducing their own risk of relapse into acts of violence and other unwanted outcome: Trust, Hope, Toolbox and Time. Time is important for other themes and forms an overarching theme. These themes reflect recovery and they can be described through a continuum that reflects the extent to which the patient participates in care. Study II shows that the central components of what patients in forensic psychiatric care perceive as personal recovery are covered within the recovery framework CHIME. However, all themes within the CHIME-framework were expanded with subcategories relevant for the care that patients in forensic psychiatry describe. In addition to this, the theme “Feeling safe and secure” emerges as a theme specific for forensic psychiatric care and is added to CHIME which is then suggested to be a specific concept for recovery in forensic psychiatric care, CHIME-S. Study III shows that the patients' risk of relapse into violence decreases when the staff chooses to work with specific critical factors namely Insight; Attitudes; Mental state; Coping; and Drug use, with a differences depending on time spent in care and differences in diagnoses. Study IV shows that START is a unidimensional instrument where the sum of strengths and sum of weaknesses, respectively, measure the same underlying construct.

Conclusions: The conclusion of study I is that patients see personal recovery as reducing their own risk of relapse into acts of violence and other unwanted outcomes. Recovery can be described as a journey along a continuum where patients have reached different stages in their development. The conclusion of study II is that personal recovery for patients in forensic psychiatry can be described in the expanded framework CHIME-S and that patients face barriers and challenges in care that affect their recovery. The conclusion of study III is that if staff choose to work with some specific of START's critical factors, the patient's risk of relapse into acts of violence and other unwanted outcome is substantially reduced. The conclusion of study IV is that START is a unidimensional instrument and that the sum of strengths and weaknesses is a reasonable measure of the degree of risk of relapse into acts of violence and other unwanted outcome.

List of scientific papers

I. It had only been a matter of time before I had relapsed into crime: aspects of care and personal recovery in forensic mental health. Charlotte Pollak, Tom Palmstierna, Magnus Kald, Per Ekstrand. J Forensic Nurs. Oct/Dec 2018;14(4):230-237.
https://doi.org/10.1097/JFN.0000000000000210

II. Personal recovery and its challenges in forensic mental health: A systematic review and thematic synthesis of the qualitative literature. [Manuscript]

III. Short Term Assessment of Risk and Treatability (START) as a care tool for risk reduction addressing critical factors. [Manuscript]

IV. Unidimensionality of the Strengths and Vulnerabilities Scales in the Short-Term Assessment of Risk and Treatability (START). Richard Whittington, Charlotte Pollak, Alice Keski-Valkama, Andrew Brown, Alina Haines-Delmont, Jesper Bak, Jacob Hvidhjelm, Roger Almvik, Tom Palmstierna. International Journal of Forensic Mental Health. 2021, 2 Aug.
https://doi.org/10.1080/14999013.2021.1953193