Experiences of restrictiveness in forensic psychiatric care: Systematic review and concept analysis

Abstract

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.

The Forensic Restrictiveness Questionnaire: Development, Validation, and Revision

“…The provision of forensic beds has been steadily increasing over the past decades in several European countries (1). A growing number of individuals are therefore placed within settings that have been described elsewhere as ‘total’, subject to prescriptive daily regimes (2, 3).…”

Perceived Institutional Restraint Is Associated With Psychological Distress in Forensic Psychiatric Inpatients

“…However, because of methodological limitations, causal conclusions cannot be drawn, and our results must be interpreted with caution. Nevertheless, our study might be able to add the aspect of psychopathology to previous findings of an association between perceived restrictiveness and both a caring vs. custodial focus and the individual risk assessment (8). One interpretation of the results might be that certain psychopathological symptoms are a result of dysfunctional adjustment to restrictive external conditions and that specific institutional characteristics might provoke specific symptoms (illustrated by the sole association of the Fairness subscale with hostility).…”

“…A recent review conceptualized perceived restrictiveness in forensic care across individual (i.e., relational, tangible), institutional (i.e., built environment, activities, culture, atmosphere, therapeutic aspects, security, practicality), and systemic (i.e., regulatory, temporal) levels; the amount of perceived restrictiveness depended on whether the focus of care was more caring (vs. custodial) and whether the resident was rated as risky (8). The authors stated that because of the negative outcomes of restrictive measures, it is necessary to reflect critically on practices, procedures, and policies in forensic care settings (8). Therefore, it seems important to better understand whether and how indirect coercion is associated with psychopathology.…”

An Interview Study of Professional Carers’ Experiences of Supporting Patient Participation in a Maximum Security Forensic Psychiatric Setting

“…Shared decision making in forensic psychiatric care has, however, an inherent setback, namely that forensic psychiatric care is rooted in a system based on restrictions and involuntary treatment (1991:1129. Restrictions include aspects such as limited leave and grounds access, the right to apprehend personal belongings, and is moderated by the attitudes of staff (Tomlin, Bartlett, & V€ ollm, 2018). This dimension of shared decision making in correctional and forensic practice has been portrayed as a dual-role problem, or dual-role dilemma, and can be described as a conflict between two sets of ethical norms, community protection (non-maleficence) and justice versus the patient's well-being (beneficence) and autonomy (Ward, 2013).…”