Forensic Mental Health Settings Research Articles

Evaluation of a novel co-designed and co-delivered training package to de-escalate violence and aggression in UK acute inpatient, PICU and forensic mental health settings.

BACKGROUND: Evidence suggests a discrepancy between recommended and routine practice in de-escalation in mental health settings, suggesting a lack of impact of existing training. To investigate the acceptability and perceived impact of a co-designed/delivered training intervention on a trauma-informed approach to de-escalation on mental health wards. Trainees were invited to complete the Training Acceptability Rating Scale (TARS) post-training. Responses to the quantitative items were summarized using descriptive statistics, and open-text responses were coded using content analysis. Of 214 trainees, 211 completed the TARS. The trainees rated the training favourably (median overall TARS = 55/63), as acceptable (median 33/36) and impactful (median 23/27). There were five qualitative themes: modules of interest; multiple perspectives; modes of delivery; moulding to context; and modifying other elements. The EDITION training was found to be acceptable and impactful, with trainees particularly valuing the co-delivery model. Trainees suggested several ways in which the training could be improved, particularly around the need for further moulding of the intervention to the specific ward contexts/teams. We recommend co-designing and co-delivering staff training to mental health professionals that tackles restrictive practices. This research is relevant to lived experience practitioners who want to be involved in training mental health professionals around restrictive practices, demonstrating the value and importance of their voice. It is relevant to current providers of de-escalation training, and to staff receiving training, outlining a novel, but acceptable and impactful, form of training on a key area of mental health practice. It is relevant to anyone with an interest in reducing restrictive practice via co-delivered training.

IT’S ALL IN THE ACTION

CASE SETTING The prevalence of metabolic syndrome in patients with serious mental illness is almost double the prevalence reported for the general population of Australia. Cardiometabolic disease and mental illness are overrepresented in adult prison populations, with people in custody significantly more likely to have cardiovascular disease and Type 2 diabetes. The Forensic Hospital, is a mental health facility with 140 beds that sits within Justice Health NSW. It is specifically designed for people who have mental illness and have been involved with the criminal justice system, as well as those who are considered to be at high risk in the community. The Ministry of Health and Justice Health NSW have several documents that make reference to the importance of screening for Metabolic Syndrome however barriers exist at the patient, staff, and organisational level to implementing the recommended physical health guidelines in a high secure forensic mental health setting. TREATMENT It’s All In The Action is a Quality Improvement project led by the Forensic Hospital’s Senior Exercise Physiologist and Rehabilitation Coordinator. The initiative focused on embedding physical health intervention for Forensic Hospital patients at risk of or diagnosed with metabolic syndrome through the establishment of the Metabolic Care Team. RESULTS A defined physical health pathway to intervention within the Forensic Hospital in the form of a physical health MDT, atypical in the Forensic Mental Health setting. REFLECTIONS/LEARNINGS The presentation will outline the steps taken in a ground up approach to address the growing concern of systemic neglect and achieve service level change. It will demonstrate translation of best practice research as well as State and National policy and guidelines into tangible action for a significantly marginalised population group. Finally, it will reflect on the sustainability of this initiative, the integration of partnerships, and recommendations for prospective next steps.

Risk and protective factors in risk assessment: Predicting inpatient aggression in adult males detained in a forensic mental health setting.

Structured clinical risk assessments represent a preferred means of assessing levels of aggression risk at different times and in different individuals. Increasing attention has been given to capturing protective factors, with sound risk assessment critical to high-secure forensic mental health care. The aim was to assess the predictive value of the HCR-20v3 for aggression risk and the long-term care pilot version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population and to determine the incremental value of protective over risk factors.Participants were adult males detained in a high secure forensic mental health service, with a primary diagnosis of schizophrenia and/or personality disorder. The focus was on examining hospital based aggression (self- and other-directed) at two time points; up to 6 months (T1) and between 7 and 12 months (T2).The HCR-20V3 and SAPROF-LC-pilot demonstrated good predictive validity but with variability across subscales and aggression types/periods. Historical factors of the HCR-20V3 and External factors of the SAPROF-LC-pilot failed to predict, aside from a medium effect at T1 for verbal aggression and self-harm, for Historical factors. There was evidence for protective factors adding to prediction over risk factors alone, with the integration of protective and risk factors into a risk judgement particularly helpful in improving prediction accuracy.Protective factors contributed to risk estimates and particularly if integrated with risk factors. Combining risk and protective factors has clear predictive advantages, ensuring that protective factors are not supplementary but important to the aggression assessment process.

Secure patient-therapist attachment following therapy for personality disorder in a forensic mental health setting

ABSTRACT Therapy for personality disorder can be understood as a process of enhancing attachment security. This study tests the theory that individuals in a secure forensic mental health setting with a diagnosis of personality disorder who have undertaken psychological therapy will report secure patterns of attachment in their relationship with their therapist. It uses a novel pattern matching approach that assesses the behavioural, cognitive and affective markers of attachment security in a group of patients undergoing therapy. Eight behavioural, cognitive and affective characteristics of secure attachment were identified. Ten patients completed a semi-structured interview about their experiences in therapy and key relationships, and their responses were reviewed for evidence of these eight characteristics. Nine out of ten participants were judged to have demonstrated a pattern of six or more of the eight characteristics of secure attachment. This study supports the theory that treatment for this group of patients works by developing patient-therapist attachments. A focus on attachment issues should, therefore, be a core aspect of therapy.

Testing a recovery-oriented nursing communication framework to encourage collaboration and discussion about aggression prevention: A mixed methods study.

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression.

Adverse Childhood Experiences, Suicidality, and Aggression as Indicators of Polypharmacy Practice in Forensic Mental Health Systems

Pharmacotherapy is a front-line intervention used to address complex health concerns among forensic system consumers. Many are prescribed a polypharmacy pharmacotherapy regimen, though this may pose significant risks to physical health and well-being. Forensic consumers also have evidence of behavioral health concerns that may impact preferred treatment and prescribing practices. We examined the relationship between ACEs, suicide, self-harm, and inpatient aggression with psychotropic polypharmacy using retrospective data extracted from medical records from a US forensic mental health facility (N = 182). Nearly all participants (98.5%) prescribed any medication (72%) received a psychotropic polypharmacy regimen. ACEs were common, impacting 75.8% of the sample. ACEs, self-harm, and inpatient aggression, though not suicide attempts, were positively predictive of psychotropic polypharmacy in a series of regression analyses. Mediation analyses explored the interplay between ACEs, specific behavioral concerns, and psychotropic polypharmacy, though only models involving self-harm were significant. Implications for trauma-informed practice include an emphasis on consumer choice, empowerment, collaboration, and autonomy. Future research should investigate implementation of trauma-informed practices in forensic mental health settings and the effectiveness of nonpharmacological interventions that can be used to reduce dependence on psychotropic medications when managing forensic consumers’ health concerns.

Enhancing Pre-Treatment Motivation Improves Forensic Mental Health Outcomes.

Despite evidence that psychological treatments benefit from pre-treatment intervention, there remains no published research on the value of including a pre-treatment intervention in forensic mental health settings. The present study aimed to address this gap by examining the effects of adding a brief motivational preparatory program (MPP) to standard forensic psychiatric care. The MPP was based on hope theory and motivational interviewing within a cognitive-behavioral therapy approach. MPP participants and a waitlist control group completed a battery of self-report measures of hope and motivation to change, which were compared with respect to risk, demographic, offence history, and outcome variables. There was a significant increase in client motivation for change after completing the MPP. Additionally, those who completed the MPP evidenced modest reductions in aggressive behavior, but significantly increased engagement in subsequent forensic treatment and programming.

An examination of service user satisfaction in forensic mental health settings.

High levels of service user satisfaction are viewed as a reliable indicator of a service providing good care and treatment. There has been limited research looking into levels of satisfaction in forensic mental health settings with most work focused on staff satisfaction in these settings. This study examined service users' levels of satisfaction with a forensic mental health service in the United Kingdom. The service covered two sites; one a purpose-built secure unit and the other based in an old cottage hospital. Thirty-nine in-patients completed a 60-item validated forensic satisfaction scale. The scale measured seven domains of satisfaction as well as reporting an overall satisfaction score. The results indicated the service users were reasonably satisfied with the care and treatment they received. The domains of rehabilitation, safety, staff interaction and overall care showed the highest level of satisfaction. The high rehabilitation satisfaction score demonstrated the importance of meaningful activities for users accessing forensic services and may have been influenced by the security measures on the wards. The high safety domain score indicated respondents felt safe and secure within the wards and were likely to be influenced by positive interpersonal interactions. Good staff interaction was also an important factor in helping service users feel safe on the wards. These interactions are likely to be associated with longer periods of admission in secure services allowing therapeutic relationships to develop. Financial advice/support was the one domain that recorded negative satisfaction levels. Financial literacy training may help develop money management skills.

A Nominal Group Technique to finalise Safewards Secure model and interventions for forensic mental health services.

INTRODUCTION: Safewards is a model developed for acute mental health settings designed to reduce conflict and containment; however, it requires adaptation to forensic mental health settings. To develop the Safewards Secure model, a model to assist forensic mental health services to reduce conflict and containment. A literature review was conducted to elicit possible modifiers and adjustments to the interventions. A Nominal Group Technique was then used to engage forensic mental health experts who had experience implementing Safewards (n = 12) to seek feedback about the suggestions and reach consensus on the Safewards Secure model and interventions. Data were thematically analysed. Experts reached consensus on all suggestions, however, did recommend minor additions and modifications. Two themes were also interpreted: Safewards Secure is just as much for staff as it is for consumers, and the proposed additions encourage more meaningful staff to consumer collaboration. This study identified key challenges experienced by nurses working in forensic mental health settings, however, these challenges were not seen as insurmountable. The Safewards Secure model offers prompts and suggestions to encourage reflection, collaboration and a humanistic approach to care in forensic mental health settings. Addressing reactions to offending behaviour and encouraging more collaboration might assist in ensuring a more person-centred approach to forensic mental health nursing care.

When the ward is the patient: Using the PRISM protocol to understand and reduce violence in an inpatient intellectual disability setting.

Violence in inpatient settings is recognised as a worldwide issue, with inpatient intellectual disability services having higher rates than other mental health settings. Violence results in injury and illness, lack of confidence in the organisation and staff burnout. These combined effects have a negative impact on the ability of services to provide therapeutic environments. Attempts to manage violence tend to focus on the individual. This is only one part of the solution. Situational risk factors for violence within secure settings can be identified and modified to reduce violence rates. The role of situational risk factors in rates of institutional violence requires consideration in addition to individual patient risk assessment and management. To discuss an illustrative case study of a ward experiencing high levels of violence, resulting in staff burnout and low morale. To describe how assessing and addressing the relevant situational risk factors led to demonstrable reductions in violence and improvements in the service provided. This case study demonstrates the practical application of assessing and managing situational risk factors for violence in a locked intellectual disability ward in order to effectively reduce levels of violent incidents. A description of the violence and critical issues faced by the ward is provided, noting key elements of the timeline of events and the application of the Promoting Risk Intervention by Situational Management (PRISM) process to address these. The PRISM protocol enabled a comprehensive assessment and understanding of situational factors relevant to the violence rates in the ward. The recommendations following the analysis enabled the management team to identify areas for immediate and long-term action. Practical steps to address issues such as improving soundproofing were implemented quickly whilst other issues required changes over the longer term. Significantly, reduced levels of violence were observed within a 2-month period of immediate steps being taken, with further gains achieved over the longer term. This paper provides the only example of the use of the PRISM protocol in an intellectual disability inpatient setting. The reduction in violence seen in this unit provides 'real world' evidence that addressing situational factors for institutional violence can be effective in intellectual disability inpatient settings, with beneficial outcomes for patients and staff. Whilst individual patient risk assessment and risk management are key components of forensic mental health care, situational risk factors for violence are highly relevant to rates of violence within secure care settings. Structured assessment of situational risk factors should be considered when inpatient settings experience persistent high levels of violence. Further research on the impact of assessing situational risk factors in forensic mental health settings (including intellectual disability services) would help to develop the existing evidence base.

Patient perspective on observation methods used in seclusion room in an Irish forensic mental health setting: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Nurses' observation of patients in seclusion is essential to ensure patient safety. Patient observation in seclusion assists nurses in adhering to the requirements of mental health legislation and hospital policy. Direct observation and video monitoring are widely used in observing patients in seclusion. Coercive practices may cause distress to patient-staff relations. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We add detailed information on specific observation methods in seclusion and compare them from the perspective of patients. Nurses communicating with patients ensures relational contact and that quality care is provided to patients even in the most distressed phase of their illness. Providing prior information to patients on observation methods in seclusion and the need for engaging patients in meaningful activities, while in seclusion are emphasized. Observation via camera and nurses' presence near the seclusion room made patients feel safe and gave a sense of being cared for in seclusion. Pixellating the video camera would give a sense of privacy and dignity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The overarching goal is to prevent seclusion. However, when seclusion is used as a last resort to manage risk to others, it should be done in ways that recognize the human rights of the patient, in ways that are least harmful, and in ways that recognize and cater to patients' unique needs. A consistent approach to relational contact and communication is essential. A care plan must include patient's preferred approach for interacting while in seclusion to support individualized care provision. Viewing panels (small window on the seclusion door) are important in establishing two-way communication with the patient. Educating nurses to utilize them correctly helps stimulate relational contact and communication during seclusion to benefit patients. Engaging patients in meaningful activities when in seclusion is essential to keep them connected to the outside world. Depending on the patient's presentation in the seclusion room and their preferences for interactions, reading newspapers, poems, stories, or a book chapter aloud to patients, via the viewing panel could help ensure such connectedness. More focus should be placed on providing communication training to nurses to strengthen their communication skills in caring for individuals in challenging care situations. Patient education is paramount. Providing prior information to patients using a co-produced information leaflet might reduce their anxiety and make them feel safe in the room. When using cameras in the seclusion room, these should be pixelated to maintain patients' privacy. ABSTRACT: Introduction A lack of research investigating the specific role that various observational techniques may have in shaping the therapeutic relations in mental health care during seclusion warranted this study. Aim The aim of the study was to explore patients' experience of different methods of observation used while the patient was in seclusion. Method A retrospective phenomenological approach, using semi-structured interviews, ten patients' experiences of being observed in the seclusion room was investigated. Colaizzi's descriptive phenomenological method was followed to analyse the data. Results Communicating and engaging patients in meaningful activities can be achieved via the viewing panel. The camera was considered essential in monitoring behaviour and promoting a sense of safety. Pixelating the camera may transform patient view on privacy in seclusion. Discussion The mental health services must strive to prevent seclusion and every effort should be made to recognise the human rights of the patient. The study reveals numerous advantages when nurses actively engage in patient communication during the process of observation. Implications for Practice Different observation methods yield different benefits; therefore, staff education in using these methods is paramount. Empowering the patient with prior information on seclusion, engaging them in meaningful activities and proper documentation on patient engagement, supports the provision of individualised care in seclusion.

Vicarious Trauma and Health Outcomes in Forensic Mental Health Nurses.

Nurses working in forensic mental health settings are at risk of vicarious trauma because of their exposure to traumatized patients and distressing material such as the aversive details of patient crimes. The aim of this study was to determine the incidence of vicarious trauma and explore its impact on health and absence from work. A cross-sectional descriptive correlational study was undertaken. All 205 forensic mental health nurses working in a high-security inpatient facility were invited to participate. An online survey included the Vicarious Trauma Scale and the SF-36v2 to measure mental and physical health. Absence from work was also explored. Sixty-seven respondents completed the survey. Almost half of respondents had a moderate level of vicarious trauma, and only over one-quarter experienced high levels. Higher levels of vicarious trauma were associated with poorer mental health ( r = -0.59, p < 0.000) and absence from work ( r = 0.27, p < 0.010). Forensic mental health nurses are at a greater risk of vicarious trauma than nurses working in mainstream mental health services, given their exposure to aversive details of patients' violent crimes. Adverse mental health consequences of vicarious trauma, and other forms of workplace trauma experienced by forensic mental health nurses, are likely to include trauma-related symptoms, depression, and anxiety. Forensic mental health nurses experiencing vicarious trauma may use sick leave as time away from work to care for their own mental health or a coping mechanism for workplace-induced psychological distress.

Peer Support-Led Interventions in Forensic Settings: Listening to Service Users and Peer Support worker’ Perceptions and Experiences

ABSTRACT Repeatedly, peer support (PS) research in mental health settings has indicated the influential impact of PS on recovery outcomes, including community reintegration and overall quality of life. Despite these findings, and the bolstering of PS in UK healthcare policy, PS remains underdeveloped in UK mental health settings. This is particularly pronounced in forensic mental health settings where the development of PS has remained heavily restricted by application difficulties in secure care models. The current study aims to provide one of the first in-depth explorations of PS experiences for both service users (SUs) and peer support workers (PSWs) in UK forensic mental health services. Semi-structured interviews were conducted with 13 participants (ten SUs, three PSWs) and analyzed using thematic analysis. Four primary themes were identified detailing the experiences and challenges of forensic-based PS: Experiences of PS from SU perspective; Experiences of PS from PSW perspective; Contrasting care: Addressing the “Us and them” divide, and Further service development. Recommendations identified for progressing PS center on integration improvements, increasing the variety of peer-led interventions, and incorporating PS’s “flexible” nature into traditional models of care. Further action is needed to develop and embed PS in forensic care, including guidance for the development of strategies and policy, and direction for future research.

Exploring the role of the nurse unit manager in forensic mental health inpatient units: A qualitative study.

Forensic mental health (FMH) inpatient settings are complex working environments at times due to a number of factors including the presence of challenging behaviours that may include violence and aggression, restrictions related to legislation, extended length of stay and the impact of trauma. Nurse unit managers (NUMs) play an important role in managing the unit environment and clinical standards of care to achieve better outcomes for consumers and staff. However, the role of NUMs in an FMH setting is poorly understood. The overall aim of this study was to explore the role of NUMs working within an FMH setting in Victoria, Australia. To our knowledge, this is the first study that has examined the subject. Data were collected via focus groups from n = 32 participants which included NUMs, their managers, staff who work alongside the NUMs and the staff the NUMs manage. Data were analysed using thematic analysis and four themes were interpreted from the data, (i) lack of role clarity, (ii) the importance of clinical Leadership and forensic mental health knowledge, (iii) step up in responsibility and step down in pay and (iv) seeing the difference you make. The role of the NUM within a forensic mental health setting comes with a number of challenges, but also opportunities to enact change. An ongoing effort to better support those employed within the NUM role and make the role desirable for aspiring staff is critical to the sustainability of a skilled clinical workforce and quality of care in this complex setting.

The Digital Bytes Project: Digital Storytelling as a Tool for Challenging Stigma and Making Connections in a Forensic Mental Health Setting.

This article reports on the findings of a study that explores the utility of digital storytelling as a narrative practice and learning tool for social work in an Australian secure forensic mental health hospital. The short digital stories, or Digital Bytes Project, centered on capturing the lived experience, hopes and perspectives of the hospital's service users by giving voice to their experiences through digital technology. The project was collaboratively designed and co-delivered with social work students, hospital staff, and service users. It aimed to not only destigmatize people with lived experiences of mental distress and criminal justice system involvement but also to give staff and students further insights into understanding who they are working with. Through a series of 11 semi-structured, one on one interviews, this research aims to explore social work student and forensic mental health staff experiences and perceptions in relation to the utility and impact of these digital bytes, reflecting on how the prototype bytes may have impacted their learnings, or practice, including how they then interact with service users. This research investigates how these digital bytes could be used further within forensic mental health organisations and contexts. The research findings demonstrate the overall value of digital bytes in challenging different kinds of stigma, shifting power dynamics and staff perspectives; strengthening rapport and understanding through enhancing engagement and sharing power between students, staff, and consumers; as well as providing insight into the utility of digital bytes for learning and making connections between theory and practice. The preliminary findings from this research suggest the need for greater accessibility, integration, and consideration of these digital tools, with their potential to be translated across multiple human service sectors.

Why do nurses seek employment in forensic mental health and what are their first impressions of the clinical environment? A mixed methods study.

The aim of the study was to investigate why registered nurses seek forensic mental health employment and explore their initial impressions of this setting. Explanatory sequential mixed methods. Registered nurses employed in a forensic mental health hospital completed an online survey about their reasons for seeking work in forensic mental health and their transition into the setting. To fully explore findings, semi-structured interviews were conducted with a sub-group of survey respondents. Descriptive statistics were used to analyse survey data, and thematic analysis was used to analyse the interviews. Sixty-nine respondents completed the survey, and 11 interviews were conducted. Prior interest in forensic mental health and encouragement from hospital staff were considered important influences in seeking forensic mental health employment. New knowledge, changes in clinical responsibility, exposure to patients' background offences and security processes overwhelmed some participants initially. However, participants reported that the initial challenges of their transition revealed opportunities to develop genuine connections with patients. This study provides a new understanding of the reasons why nurses seek employment in forensic mental health and the challenges and opportunities experienced when first working in this setting. Such professional and personal elements need to be considered by organizations to strengthen recruitment strategies and support future nurses' transition into forensic mental health settings. This study provides new knowledge about recruiting and supporting nurses' transition into forensic mental health employment. As such, it informs policymakers, clinical services and managers about strategies needed to attract and retain this workforce. No public or patient involvement.

Legal and human rights issues in the use of electronic monitoring (using GPS 'tracking' technology) in forensic mental health settings in the UK.

Electronic monitoring (EM) of individuals has been used by the criminal justice system for the past thirty years, and in the UK, use is on the increase. Its use has been justified as an alternative to prison to reduce recidivism and allowing early release of prisoners, however, the evidence base for this remains mixed. In 2010, it was employed for the first time in a forensic psychiatry setting. A study investigating the effects of EM on leave episodes concluded that EM may improve the speed of patient progress and reduce the length of admission, leading to reduced costs and increased public safety. However, the intervention generated considerable controversy and sparked discussion about ethical concerns. Here, we consider specifically legal and human rights issues that emerge from use of EM in forensic healthcare settings, scrutinising its use in the context of the Mental Health Act and the Human Rights Act. We conclude that EM is legal and justifiable, providing it is used judiciously and with due consideration of concerns for the individual and the given context.

The Need for Practicable Normative Right-based Social Work Practice in Secure and Forensic Mental Health Services

Abstract We (both author and reader) will explore the need to develop a practicable evaluative human rights-based approach to the care, treatment and discharge of forensic mental health patients. It can be argued that patients in secure and forensic services are potentially the most marginalised and extensively stigmatised of all patient cohorts, and that the extent to which they are discriminated against should not be underestimated. We will consider the concept of right-based practice in secure and forensic mental health settings, and how the quality of practice can be strengthened. We will ground our exploration in the lived experiences of secure and forensic mental health patients and seek through the lens of lived experience to envisage what could constitute fairer and more supportive systems of care.

"Recovery" in mental health services, now and then: A poststructuralist examination of the despotic State machine's effects.

Recovery is a model of care in (forensic) mental health settings across Western nations that aims to move past the paternalistic and punitive models of institutional care of the 20th century and towardmore patient-centered approaches. But as we argue in this paper, the recovery-oriented services that evolved out of the early stages of this liberating movement signaled a shift in nursing practices that cannot be viewed only as improvements. In effect, as "recovery" nursing practices became more established, more codified, and more institutional(ized), a stasis developed. Recovery had been reterritorialized. The purpose of this paper is to examine some of the threads of recovery, from its early days of antipsychiatry activism to its codification into mental health-including forensic mental health-institutions through the lens of poststructuralist philosophers Gilles Deleuze and Felix Guattari. We believe that Deleuze and Guattari's scholarship provides the necessary, albeit uncomfortable, framework for this critical examination. From a conceptualization of recovery as an assemblage, we critically examine how we can go about creating something new, caught in a tension between stasis and change.

Poststructuralism and the construction of subjectivities in forensic mental health: Opportunities for resistance.

Nurses working in correctional and forensic mental health settings face unique challenges in the provision of care to patients within custodial settings. The subjectivities of both patients and nurses are subject to the power relations, discourses and abjection encountered within these practice milieus. Using a poststructuralist approach using the work of Foucault, Kristeva,and Deleuze and Guattari, this paper explores how both patient and nurse subjectivities are produced within the carceral logic of this apparatus of capture. Recognizing that subjectivities are fluid and dynamic, and capable of change, Deleuze and Guattari's concept of deterritorialization will illustrate opportunities for resistance, where nurses can begin to practice outside the dominant carceral logic (and restrictions) of the system.