Forensic mental health professionals’ perceptions of their dual loyalty conflict: findings from a qualitative study

Abstract

Background Mental health professionals (MHP) working in court-mandated treatment settings face ethical dilemmas due to their dual role in assuring their patient’s well-being while guaranteeing the security of the population. Clear practical guidelines to support these MHPs’ decision-making are lacking, amongst others, due to the ethical conflicts within this field. This qualitative interview study contributes to the much-needed empirical research on how MHPs resolve these ethical conflicts in daily clinical practice. Methods 31 MHPs working in court-mandated treatment settings were interviewed. The interviews were semi-structured and our in-depth analysis followed the thematic analysis approach. Results We first outline how mental health professionals perceive their dual loyalty conflict and how they describe their affiliations with the medical and the justice system. Our findings indicate that this positioning was influenced by situational factors, drawing the MHPs at times closer to the caring or controlling poles. Second, our results illustrate how participating MHPs solve their dual loyalty conflict. Participants considered central to motivate the patient, to see the benefits of treatment and its goals. Further, transparent communication with patients and representatives of the justice system was highlighted as key to develop a trustful relationship with the patient and to manage the influences from the different players involved. Conclusions Even though individual positioning and opinions towards dealing with the influences of the justice system varied, the results of our research show that, in spite of varying positions, the underlying practice is not very different across participating MHPs. Several techniques that allow developing a high-quality therapeutic alliance with the patient are key elements of general psychotherapy. Transparency appears as the crucial factor when communicating with the patient and with representatives of the justice system. More specifically, patients need to be informed since the beginning of therapy about the limits of medical confidentiality. It is also recommended to develop guidelines that define the level of detailed information that should be disclosed when communicating with the authorities of the justice system.

The perspective of staff members of two forensic psychiatric clinics in German-speaking Switzerland on the introduction of recovery orientation: An explorative study

“…Working in a forensic psychiatric ward, an “ often hostile and unpredictable environment ” ( 29 ) is inevitably entangled with the challenge of finding a functional balance regarding the tension between security and therapy ( 13 , 14 , 30 – 33 ). Thereby, situational factors settled within the institutional and juridical framework of forensic psychiatry have a critical influence on the staff’s mode, attitudes, core values, and philosophy of working.…”

“…The staff, on the other hand, has to deal with the dual mission of forensic psychiatry, namely the contrast between therapy and safeguarding society from possible threats through the criminal behavior of these patients ( 13 ). This tension may cause inner loyalty conflicts that result in cycling between control and care ( 14 ). Correspondingly, in the context of a concept analysis of restrictiveness, Tomlin et al ( 15 ) showed that being either caring or patronizing is an inherent aim of the forensic system; thereby, for instance, patients described staff members as key-holders, lacking in empathy, insensitive, disempowering, forceful, abusive, prone to over-reaction [( 16 ), p. 34] with regard to patronization.…”

‘Fleeing’ as a Strategy for Navigating Resistance in Patient Encounters within Forensic Care

“…This aspect is characterized by a tension between knowledge and ignorance, that is, being between conflicting feelings that are linked to insecurity in one's professional role, logically, a view about local, bodily, and experience-based knowledge. A key strategy in forensic psychiatry to establish a caring relationship is transparency and openness from the carer [40]. According to Martinsen [41], the phenomenological starting point is that our openness to the world shall be taken seriously (i.e., that we are open-minded, attentive, and concerned in the place of impressions).…”