Caregiver perspectives on patient capacities and institutional pathways to person centered forensic psychiatric care

Abstract

The ethical discourse surrounding patients’ agential capacities, vis-à-vis their active participation in shared decision-making (SDM) in forensic psychiatric (FP) contexts, is an unexplored area of inquiry. The aim of this paper is to explore caregivers’ perceptions of patient agential capacities and institutional pathways and barriers to person centered care (PCC) in the context of FP. Following an exploratory qualitative design, we conducted eight semi-structured interviews with hands-on caregivers at an in-patient FP facility in Sweden. A deductive framework method of analysis was employed, and four themes emerged: “Fundamental Variability in Patient Capacity”, “Patient Participation: Narration or Compliance?”, “Antagonism Rooted in Power Struggles”, and “System Structure Thwarts Patient Release”. While the results generally paint a bleak picture for the possibility of a person-centered FP care, we describe a constrained version of PCC with high-level SDM dynamics which promotes a certain degree of patient empowerment while allowing care strategies, within set restrictions, to promote patient adherence and treatment progress.

Forensic psychiatric patients’ experiences of participating in administrative court proceedings concerning the continuation of forensic psychiatric care

“…Patients describe their experience of hearings in administrative court as mainly being focused on risk and dangerousness, and that this predominates other factors they consider important, reinforcing an image of themselves as dangerous, and together with the perceived empty formality of the proceedings, as hopeless cases. This links to an observation by El-Alti and colleagues ( 16 ) that the complexity and rigidity of the care system can affect the care progression negatively, and that the court proceeding is a crucial arena for the patients’ experiences of care progression or its opposite. The patients can in this type of system view themselves as someone in continuous need of risk assessment and strict control.…”

“…It is obvious in this study that this fact is difficult to comprehend for the patients, where the participants say, for example, “the oral hearing is unnecessary” “getting healthy is not enough,” and perceive that the staff are in agreement with them. The underlying origin of this is a longstanding issue in the ethics of forensic psychiatry about the ultimate goals of this practice, and how a complex goal structure leads to conflicting notions about the aim and value of the care ( 16 , 24 ). This study confirms that this dilemma is vividly experienced also by the patients in relation to the administrative court hearings.…”

“…Thus, if the aim of forensic psychiatry is set as the minimizing of the risk of reoffending in general, the care may succeed in psychiatric terms but still be bound to fail in terms of risk prevention. Vivid experiences of precisely this dilemma have been described in a recent study of Swedish forensic psychiatric care ( 16 ). Buchanan and Grounds ( 30 ) argue that this situation is likely to arise in a social and political environment that emphasizes crime prevention as a major and dominant value.…”

“…Discussions about oral hearings might in a way touch the most essential core of the complexity in forensic psychiatric care, it is hard to discuss the outcome from the oral hearings without considering the reasons for why the patient will remain in the care and what must be accomplished to be discharged. This is a difficult task from a staff perspective, especially since the goal for forensic psychiatric care is unclear ( 16 ).…”

“…Both staff and patients have reported patient participation being a challenge in forensic psychiatry in previous studies (11)(12)(13)(14)(15)(16). One reason may be that the forensic psychiatric process is difficult to understand and is experienced as being slow and complex.…”