Abstract
BackgroundSome forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues. Research focused on the patients in secure care has examined quality of life and service provision but not the perspectives of patients experiencing long stays. This study explored how long stay patients experience secure care, what factors they felt influenced long stay, and its impact upon treatment engagement and motivation to progress.MethodsEmbedded within a larger epidemiological study, we conducted semi-structured interviews with a purposive sample of forty long stay patients from two high and six medium secure hospitals. Long stay was defined as a 5 years stay in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure. Transcripts were subject to thematic analysis, and narrative analysis at individual case level to explore the relationship between emergent themes.ResultsFour themes emerged illustrating participants’ attribution, outlook, approach, and readiness for change. A typology of four long stay stances was developed (dynamic acceptance, dynamic resistance, static acceptance, static resistance). These illustrate differences in the extent to which participants believed being in secure care helped them to get better, and actively work towards progression and leaving secure care. There were considerable differences in how patients adopting these stances attributed the reasons for their long stay, they viewed their future, and their motivation to progress. Negative perceptions arose from excessive restrictions, treatment repetition and changes in therapeutic relationships, leading some patients to exhibiting tokenistic engagement and low motivation to progress.ConclusionsPlanning care for long stay patients in secure psychiatric settings should take account of the differing stances patient’s adopt towards engagement and progression. Service providers should be mindful of these stances and provide patients with individualised opportunities to progress through the secure care treatment pathway, avoiding treatment repetition and maintaining continuity in key professional relationships. Refocusing on quality of life may be appropriate for some long-term patients who are unwilling or unable to move on. For some long-term patients, purpose designed long stay setting may be appropriate.
Highlights
Some forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues
In England, inpatient forensic psychiatric care is available at three high security National Health Service (NHS) hospitals and, at the time of this study, 57 medium secure units, some run by NHS Trusts and others by independent providers
Eleven patients were recruited from NHS high secure units, seventeen from NHS medium secure units and twelve from independently-run medium secure units
Summary
Some forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues. In the UK, patients are admitted to secure forensic services because they have a history of serious violence and pose a serious or grave risk to the public [7]. The aims of such detention are to (a) provide care and treatment designed to improve mental health and facilitate recovery, and (b) provide protection to the public by reducing the potential risk posed by the patient [20]. Patients may be moved between hospitals of different levels of security
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