Staffs perception of Patients’ affiliation and control in a Highly Secure Psychiatric Setting
درک کارکنان از وابستگی و کنترل بیماران در یک محیط روانی کاملاً ایمن-2019
Effective interactions between patients and staff have been associated with positive ward climate and therapeutic effects, but also pose a challenge in high secure forensic psychiatric settings. The goal of this study was to gain more insight into i) the characteristics that play a role in how staff members perceive the interpersonal style of patients, and ii) whether these perceptions are related to patients’ evaluation of ward climate and satisfaction with daily staff. Staff members (n=69), rated the interpersonal style of 102 male patients. Satisfaction with daily staff and ward climate were rated by 45 patients. Results show that patient characteristics (primary diagnosis, patient age, disruptive behavior, recent problems with symptoms of major mental disorder and recent problems with treatment or supervision response) were related to how staff perceived the interpersonal style (i.e., affiliation and control) of patients. Furthermore, the level of affiliation was positively related to patients’ satisfaction with daily staff. Patients that were seen as more controlling by staff were less satisfied with the safety on their ward (as a factor of ward climate). The results indicate that perception of patients’ interpersonal style entails patient related information and can be relevant for staff to use in their work.
Keywords: Interpersonal style | Forensic psychiatric patients | Staff members
Ethical issues of long-term forensic psychiatric care
مسائل اخلاقی مراقبت های روانی پزشکی قانونی طولانی مدت-2016
Forensic psychiatry is a subspecialty of clinical psychiatry that operates at the interface between law and psychiatry. It is concerned with patients who have a mental disorder as well as having committed an offence, often serious. Forensic psychiatric institutions are highcost/low-volume services that impose significant restrictions upon their residents. Patients may be detained in those services against their will for lengthy periods, potentially life-long. The purpose of this detention is seen as two-fold: care and treatment for the patient and protection of the public from harm from the offender. Here we review the ethical issues around such longterm detention. We base our observations on a review of relevant literature and from focus groups with professionals working in forensic psychiatric settings. Additionally, we visited three institutions in the UK where long-stay forensic psychiatric patients receive care. A number of factors have been identified contributing to long-term stay (long-stay) in forensic psychiatric care, including organisational factors (e.g., lack of beds in less secure settings) and patient characteristics (severity of psychopathology and offending). Long-stay in a forensic psychiatric setting — which is often longer than had the patient received a prison sentence for the same offence — poses significant ethical and human rights issues, particularly when it is unclear whether the treatments offered benefit the patient and when risk management considerations may outweigh the best interests of the patient. The main topics of concern identified by our participants included ‘‘system failures’’, ‘‘avoidance of warehousing’’, ‘‘importance of hope’’, ‘‘denial’’ and long-stay units and ‘‘quality of life’’. Participants were concerned that the system is set up in a way that does not allow patients with complex and long-term needs to move to more appropriate, less restrictive settings and that the issue of ‘‘long-stay’’ is met with denial. In order to avoid warehousing and maintain hope, those we spoke to felt it was important to not give up on patients and continue to deliver treatment, almost regardless of its effect. Providing long-stay patients with a good quality of life was seen as important, though we found that the stated ambitions were not always matched by the reality of the units we visited. Despite the stated need to provide something ‘‘different’’ for long-stay patients, the units were nevertheless very restrictive in their approach (e.g., prohibition of sexual expression). Professionals seemed to lack a more ambitious and creative vision to create something truly distinct. We discuss possible solutions, including explicitly maximising the quality of life of those detained, limiting the time of detention to equal the sentence length of non-disordered offenders and locating the public protection function of the management of mentally disordered offenders within the criminal justice rather than the health care system. The implementation of such radical solutions, however, might be hampered by the difficulties in changing entrenched values and procedures, to the point that diverse stakeholders join together in maintaining the status quo.
KEYWORDS: Forensic psychiatry | Mentally disordered | offenders | Long-stay | Ethics | Mental health law | Human rights