International developments in the provision of recovery‐oriented care in forensic mental health services

Forensic mental health services are tasked with providing care to some of the most clinically complex and marginalized persons in society. Indeed, forensic service users are often doubly stigmatized, owing to their status as persons with mental illness and the fact that they have offended, which results in complex and multi-layered challenges to recovery. The last decade has seen growing recognition that patient recovery and rehabilitation are integral aspects of forensic psychiatric practice. This is reflected in the expanding literature on “secure recovery”, referring to the application of general mental health recovery principles to forensic settings. This includes a growing knowledge of staff and patient perceptions of recovery-oriented care in forensic settings, as well as an increasing experience in the identification and measurement of core elements of recovery in these settings1. Five key elements of people's experiences of recovery in mental illness have been described in the literature: Connectedness, Hope and optimism about the future, Identity, Meaning in life, and Empowerment (CHIME)2. This CHIME framework has been recently extended to reflect the experiences of forensic service users, based on a systematic review and thematic synthesis of the relevant literature1. The result has been a robust conceptual framework to guide recovery-oriented practices in forensic mental health services (the “CHIME-S”). It has been documented that recovery in forensic mental health encompasses the same CHIME elements, but with the added domain of safety and security (the “S” in CHIME-S). In developing the CHIME-S framework, the centrality of therapeutic relationships with clinical staff in patient recovery, especially considering the long lengths of stay that characterize forensic hospitalizations, emerged clearly. This literature also highlighted the importance of therapeutic opportunities to elaborate the impacts of previous trauma, victimization and offending in the course of developing a new identity that is separate from that of the “offender-patient”. The ultimate goal of regaining one's freedom, independence and autonomy was particularly salient among forensic service users, as were the perceived barriers to recovery in forensic care (e.g., feelings of disconnectedness, hopelessness, stigma and disempowerment). Perhaps the greatest challenge encountered when bringing a recovery framework into forensic settings is a perceived tension between core recovery principles, such as promoting autonomy and patient empowerment, and the security and legal obligations encompassed by forensic services3. This tension can result in skepticism about whether true recovery is possible in the context of secure hospital settings where liberty and autonomous decision-making are significantly curtailed. However, in the context of forensic care, security and therapy can be synergistic rather than competing aspects. On a day-to-day basis, this can be reflected in clinical practices that strive to deliver compulsory care respectfully and therapeutically, while preserving as much patient choice and control as possible. Further, shared decision-making models around the assessment and formulation of violence risk are important vehicles through which patient voice and engagement can be promoted. New tools that require both patient and staff perspective on clinical progress and risk understanding, such as the Early Recognition Method (ERM)4 and DUNDRUM 3 and 45, are examples of structured approaches that give space to patient voice and shared vision during the process of secure recovery. Interestingly, though, secure recovery conflicts with human rights arguments that all forms of coercion must be abolished, including detention in hospitals. This is despite the growing evidence that people can and do recover in situations of security, particularly so if care is oriented towards values of respect, inclusion, maximizing voice, and building positive therapeutic alliances1. Secure recovery envisages a “whole of life” concept of service delivery, including understanding people's life history, their respectful involvement in their care, and assisting them in being fully involved as family members, workers, and members of society. It is also increasingly clear that secure recovery cannot fully come to fruition in the absence of cultural considerations and the incorporation of one's cultural identity into forensic assessment, formulation and treatment. There is an increasing awareness of the inequities afflicting many persons who receive forensic care, and how such inequities complicate their recovery efforts. Forensic mental health services are now increasingly urged to take a position of advocacy addressing these inequities6, an urgency that is amplified by the fact that many forensic services internationally comprise an over-representation of Black, Indigenous and other racialized groups. In spite of this, the integration of culturally-responsive assessment and treatment frameworks in forensic service delivery is often lacking, and there is an absence of literature to guide forensic services in the provision of equitable, diverse and inclusive practices for patients, families and staff6. Promoting cultural responsiveness to the needs of patients requires strong family engagement and regular opportunities to share knowledge and experiences. Shared decision-making models will facilitate a mutual understanding – between the patient, his/her loved ones, and the clinical team – of the person's particular pathway to risk, and will help to co-develop an understanding of clinical and personal pathways to safety. Without patient and family involvement and cooperation, relevant information for treatment and risk management planning is more likely to go unreported4, while respectful and collaborative clinician-patient relationships can promote open communication of risk and safety concerns from both patients and family members. Further, forensic patients continue to experience significantly poorer health and safety outcomes compared to non-forensic service users across a number of indicators, including premature mortality, obesity, and violent victimization7, which are often ignored. The rapidly increasing body of research on secure recovery reflects a change in forensic clinical practices internationally to align care with recovery-oriented principles. There is also a notable consistency across studies concerning the core elements of secure recovery, and their intersection with recovery principles in general mental health services. There is a perceived need to describe and develop high functioning systems of care that can represent exemplars of practice. However, research describing outcomes of forensic care has proven difficult, and evidence on the effectiveness of “treatment as usual” (TAU) is hampered by a lack of consistency across services in setting quality standards and guidelines for TAU8. Forensic mental health services are high cost, and provide care to persons seen as presenting a high risk of harm to self and others. This demands that care be personalized, carefully delivered, and guided by demonstrable quality standards to ensure continuously improving outcomes for patients8. One key component of this is to develop and propagate a well-articulated model of care (MOC) that outlines best practices for patients at different stages of recovery. The MOC describes key functions that the service must deliver, including goals, pathways and processes of care, therapeutic programming, and service measurement and evaluation. Several forensic services around the world have developed such a MOC and employ it in all components of service design and delivery. Evidence of MOC success can be collected through measurable performance indicators at the organizational (e.g., sustainable admission and discharge rates; rates of violence, restrictive practices, and absconding) and individual (e.g., symptomatic and personal recovery) levels9. It is from these developments that the aspiration to excellence in forensic care provision can emerge, including the systematic implementation and evaluation of secure recovery-oriented care, and strategies that deliver on improving “real world” outcomes for patients – including personal, symptomatic and functional recovery – and the resumption of autonomy and responsibility in the community.