Background There has been a call for a framework to guide recovery-oriented practices in forensic mental health services. Aims This study aims to examine personal recovery and its challenges in forensic mental health settings in relation to the established framework for personal recovery in mental illness: connectedness, hope, identity, meaning and empowerment (CHIME). Method This study is an updated and expanded systematic review and thematic synthesis of the qualitative literature. A systematic search of six electronic databases (Web of Science, Medline, PsycINFO, CINAHL, EMBASE and SocIndex) was carried out in January 2019, using the terms [Recover*] AND [Forensic OR Secure] AND [Patient* OR Offend* OR Service User*]. Only studies that included service user's own perceptions and were published from 2014 onward were included in the review. Data were examined with thematic synthesis and subsequently analysed in relation to the CHIME framework. Results Twenty-one studies were included in the review. Findings suggest that some adjustments to the original CHIME framework are needed for it to be more relevant to forensic populations, and that an additional recovery process regarding feeling safe and being secure (safety and security) could be added to CHIME, providing the CHIME-Secure framework (CHIME-S). Specific challenges and barriers for forensic recovery were identified and found to represent the opposite of the recovery processes defined by CHIME (e.g. hopelessness). Conclusions We present the CHIME-S as a framework for the personal recovery processes of forensic mental health service users. The CHIME-S may guide the recovery-oriented work of forensic mental health services.

Increased attention to the civil rights of general psychiatric patients has been an issue for over 30 years. Similar processes in forensic settings have been slower, because of safety and security needs. This paper explores the development of patient autonomy, as well as rates of violence and escape incidents, in a Norwegian high-security forensic psychiatric ward over an 18-year period. A historical documentary method was applied using quantitative and qualitative data. Multiple sources were analyzed, including focus group interviews among current and former staff, reviewing of official documents and staff notes, and examination of records of violent incidents and escapes. Several indicators of increased patient autonomy were found. These were paralleled by more dynamic and individualized routines for treatment and managing risk, new laws, and changed staff characteristics over the study period. Violent incidents decreased, and frequency of escape has remained low. We conclude that maintaining security is compatible with increased patient autonomy and a more normalized everyday life in forensic settings. We infer that changes in patient-staff interactions, related to implementation of relational and dynamic security, may have influenced the process toward increased patient autonomy.

Confirming these three dimensions of inpatient aggressive incidents may help caregivers' understanding of aggressive behaviour. If confirmed in future studies, this dimensional approach may prove useful for the management of aggressive inpatients.

Background: Contextual variables such as staff characteristics, treatment programs, assessment routines and administrative structures are found to influence patient violence rates in psychiatric forensic wards. The possible effects of current developments in treatment philosophy emphasizing patientsˈ perspective and treatment involvement upon violence rate have not yet been examined. The aim of this paper is to analyse associations between such developments and the occurrence of violent incidents among patients in a high security forensic psychiatric ward. Methods: During a 17-year period with stable ward conditions, incidents of violence were systematically collected together with diagnostic, risk assessment and demographic patient characteristics. Changes in care-and organizational related variables such as nursing staff characteristics, treatment and management routines were collected. Multilevel modelling was applied to estimate the relationship between these variables and changes in violent incidents. Results: A substantial decline in the occurrence of violent incidents paralleled with changes in the ward during the middle phase of the study period. Most of the changes, such as implementation of new treatment and care routines and an increased proportion of female staff and higher education levels, were significantly related to a decrease in the occurrence of violent incidents in the ward. Conclusions: Findings in this study suggest that an increase in individualized, patient-oriented care strategies, delivered by well-educated nursing staff with an equally balanced gender distribution contribute to a low level of violence.

The pattern of aggressive and violent behaviour in a maximum security forensic hospital ward, assessed by the Staff Observation Aggression Scale over a 10-year period is described. These results are compared to two other similar Norwegian projects addressing patient violence in a forensic hospital setting. Over 90% of patients had a primary diagnosis of psychotic, and 50% had a secondary diagnosis of personality disorder. Twenty percent of patients caused 80% of violent encounters, and most encounters appeared to result from limit setting actions. Only 36% of violence was viewed by staff as without clear precipitant. Female patients caused 50% more violent encounters than their representation among the patient population, but their violent behaviour was less dangerous and more often directed toward female staff than that of male patients. Overall staff were far more likely to be the targets of violence than other patients.