Recovery capital among migrants and ethnic minorities: A qualitative systematic review of first-person perspectives.

This systematic review of 15 qualitative studies explores recovery capital among migrants and ethnic minorities (MEM). The results of the framework analysis indicate that addressing barriers to recovery and (often minority-related) root causes of problem substance use is vital to recovery among MEM, as well as building recovery capital on personal, social and community level. The review unpacks the importance of "cultural" and "spiritual" elements of recovery capital both inside and outside treatment, the interconnectedness of the different dimensions of recovery capital, as well as their intertwinement with root causes of substance use and barriers to recovery. The results point out the importance of offering culturally and trauma-sensitive relational support and building recovery capital through recovery-oriented systems of care. Moreover, this study highlights the need for further research concerning recovery in MEM populations.

A qualitative inquiry on recovery needs and resources of individuals with intellectual disabilities labelled not criminally responsible.

BACKGROUND: Recovery is a widely accepted paradigm in mental health care, whilst the correctional and forensic-psychiatric field is still searching for foundations for its implementation. Knowledge regarding recovery of persons with intellectual disabilities in secure contexts is limited. This study assesses recovery needs and resources among persons with intellectual disabilities labelled not criminally responsible and investigates the impact of the judicial label on recovery processes. METHODS: A sample of 26 individuals was composed purposively, and in-depth interviews were conducted. Recurrent themes were identified using thematic analysis. RESULTS: Traditional recovery themes emerged from the narratives, next to aspects of recovery in a forensic or correctional context. However, the operationalization and proportional impact are specific for this sample. CONCLUSIONS: The social dimension overarches all other recovery dimensions. The integration of an explicit social rhetoric is imperative, including contextual, relational, interactional and societal dimensions. This offers pathways to reverse the traditional, paternalistic model of exclusion and classification.

The health-related social costs of alcohol in Belgium.

BACKGROUND: Alcohol is associated with adverse health effects causing a considerable economic impact to society. A reliable estimate of this economic impact for Belgium is lacking. This is the aim of the study. METHODS: A prevalence-based approach estimating the direct, indirect and intangible costs for the year 2012 was used. Attributional fractions for a series of health effects were derived from literature. The human capital approach was used to estimate indirect costs, while the concept of disability-adjusted life years was used to estimate intangible costs. Sensitivity and scenario analyses were conducted to assess the uncertainty around cost estimates and to evaluate the impact of alternative modelling assumptions. RESULTS: In 2012, total alcohol-attributable direct costs were estimated at €906.1 million, of which the majority were due to hospitalization (€743.7 million, 82%). The indirect costs amounted to €642.6 million, of which 62% was caused by premature mortality. Alcohol was responsible for 157,500 disability-adjusted life years representing €6.3 billion intangible costs. CONCLUSIONS: Despite a number of limitations intrinsic to this kind of research, the study can be considered as the most comprehensive analysis thus far of the health-related social costs of alcohol in Belgium.

The impact of drug treatment courts on recovery: a systematic review.

INTRODUCTION: Earlier reviews regarding the effectiveness of Drug Treatment Courts (DTCs) reported a reduction in reoffending and substance use. Although substance users suffer from other difficulties than drug use and judicial issues, none of these reviews focused on outcomes or effects of DTCs on drug-related life domains, such as social relationships, employment, or health. Therefor, the present paper aims to review the impact of adult DTCs on substance use and drug-related life domains. METHOD: Primary studies were systematically searched in Web of Knowledge. Observational and controlled evaluation studies of adult DTCs were considered eligible if substance use and/or drug-related life domains were measured. RESULTS: Moderately positive results were found with respect to within-program substance use. Few studies used drug-related life domains as an outcome measure and most of them yielded no effects. Employment and family relations ameliorated when specific interventions were used. DISCUSSION: DTCs yield beneficial outcomes and effects regarding within-program substance use. However, evidence regarding the impact of DTCs on post-program drug and alcohol use and on other drug-related life domains is scarce. These life domains and thus QoL possibly can be improved by DTCs if specifically targeted. Future research is warranted.

Tailoring the continuum of care for substance use problems to persons with an Islamic migration background: a co-creative case study.

Introduction: Structural inequity and stigma impose barriers toward substance use prevention and recovery support for persons with an Islamic migration background in non-Islamic majority countries. Similar issues of differential power often keep them silenced in research. Therefore, we explore the continuum of care for substance use problems regarding persons with an Islamic migration background. Methods: We draw from a co-creative case study with Arafat, whose lived and professional experiences as a Muslim with a history of problem substance working in the field, were blended with academic literature through the process of 'plugging in'. Results: We discuss (1) culturally competent and selective substance use prevention, (2) facilitating access to adequate support services, (3) culturally competent substance use treatment and (4) supporting long-term recovery for persons with an Islamic background from a combined academic, professional and lived experiences perspective. Discussion: We discuss the need for tailored interventions that are able to overcome structural inequities and address ethnocultural sensitivities, needs and strengths. Intermediary community organizations, cultural competence of treatment and recovery-oriented systems of care may bridge the gaps between what is needed and what is available. However, it is important to be conscious that hands-on solutions at the personal level do not absolve the responsibility of searching for systemic solutions. Furthermore, awareness of the fine line between cultural competence and culturalization, taking into account the danger of essentializing, othering and overlooking other intersectional traits of diversity, is needed.

"Recovery came first": desistance versus recovery in the criminal careers of drug-using offenders.

The aim of our paper is to gain insight in the desistance process of drug-using offenders. We explore the components of change in the desistance process of drug-using offenders by using the cognitive transformation theory of Giordano et al. as a theoretical framework. The desistance process of drug-using offenders entails a two-fold process: desistance of criminal offending and recovery. The results however indicate that desistance is subordinate to recovery because of the fact that drug-using offenders especially see themselves as drug users and not as "criminals." Their first goal was to start recovery from drug use. They were convinced that recovery from drug use would lead them to a stop in their offending. In the discussion, we explore the implications of this result for further research.

Voices to be heard: Understanding family perspectives in forensic care trajectories.

Introduction: De-institutionalization of psychiatric care has greatly increased the role of family members in the recovery pathways of Persons labeled as Not Criminally Responsible (PNCR). However, the role of family members in supporting PNCR in forensic psychiatric care remains understudied. Scarce evidence indicates that PNCR have to deal with stigma and endure specific burdens (i.e., symptom-specific, financial, social, and emotional). Recovery-focused research showed that recovery in both persons with a severe mental illness and family members develop in parallel with each other and are characterized by similar helpful principles (e.g., hope and coping skills). As such, the recovery pathways of PNCR often goes hand in hand with the recovery pathway of their family members. During the family recovery process, family members often experience not being listened to or being empowered by professionals or not being involved in the decision-making process in the care trajectory of their relative. Therefore, the aim of this study is to capture how family members experience the care trajectories of their relatives, more specifically by looking at family recovery aspects and personal advocacy of family members. Methods: Semi-structured interviews were conducted with 21 family members of PNCR from 14 families. A thematic analysis confirms that family members suffer from stigma and worry significantly about the future of their relative. Results: Regarding the care trajectory of PNCR, family members experienced barriers in multiple domains while trying to support their relative: involvement in care and information sharing, visiting procedures, transitions between wards, and the psychiatric and judicial reporting by professionals. In addition, family members emphasized the importance of (social) support for themselves during the forensic psychiatric care trajectories and of a shared partnership. Discussion: These findings tie in with procedural justice theory as a precondition for family support and family recovery within forensic psychiatric care.

Recovery Capital among Migrants and Ethnic Minorities in Recovery from Problem Substance Use: An Analysis of Lived Experiences.

Migrants and ethnic minorities (MEM) are known to be disadvantaged concerning risk factors for problem substance use and resources to initiate and sustain recovery (i.e., recovery capital). Yet, the voices of MEM are largely overlooked in recovery literature. This study explores recovery capital through 34 semi-structured interviews with a diverse sample of MEM in recovery in two ethnically diverse cities in Belgium. A Qualitative Content Analysis using recovery capital theory allowed us to identify various recovery resources on a personal, social, and community level. While physical and human recovery resources play a central role in participants' narratives, personal recovery capital is closely intertwined with meaningful social networks (i.e., social recovery capital) and recovery-supportive environments that maximize opportunities for building culturally sensitive recovery capital (i.e., community recovery capital). Though MEM-specific elements such as culture, migration background, stigma, and structural inequalities play a significant role in the recovery resources of MEM, the largely "universal" nature of recovery capital became clear. The narratives disclose a distinction between "essential" and "acquired" recovery capital, as well as the duality of some recovery resources. The need for developing recovery-oriented systems of care that are culturally responsive, diminish structural inequalities, and facilitate building recovery capital that is sensitive to the needs of MEM is emphasized.

Pains of Imprisonment Beyond Prison Walls: Qualitative Research With Females Labelled as Not Criminally Responsible.

Research on the importation and deprivation models has focused almost exclusively on male inmates, and these models have not yet been studied in any setting other than prison. This research explores the importation and deprivation experiences of females labelled as not criminally responsible (FNCR). During the first part of the study, all the participants interviewed were in prison (n = 51). Follow-up interviews were carried out 18 months later, and while some participants were still in prison, others had been moved to (forensic or general) care. At that point, the study transcended the prison walls and extended its theoretical framework to forensic and general care facilities. In conclusion, the importation and deprivation framework, and the pains defined by Crewe, can be applied to FNCR in different types of setting. Most women were strongly affected by deprivations in prisons and in forensic care. Participants in forensic care sometimes felt more deprived than those in prison facilities.

What Differentiates Prisoners Who Attempt Suicide from Those Who Experience Suicidal Ideation? A Nationally Representative Study.

OBJECTIVE: Many people who think about suicide do not engage in suicidal behavior. Identifying risk factors implicated in the process of behavioral enaction is crucial for suicide prevention, particularly in high-risk groups such as prisoners. METHOD: Cross-sectional data were drawn from a nationally representative sample of 17,891 prisoners (79% men) in the United States. We compared prisoners who attempted suicide (attempters; n = 2,496) with those who thought about suicide but never made an attempt (ideators; n = 1,716) on a range of established risk factors. RESULTS: More than half (59%) of participants who experienced suicidal ideation had also attempted suicide. Violent offending, trauma, brain injury, alcohol abuse, and certain mental disorders distinguished attempters from ideators. CONCLUSION: Our results fit within recent ideation-to-action theories that emphasize the role of a capability for suicide in the transition from thoughts to acts of suicide.

Factors associated with the transition from suicidal ideation to suicide attempt in prison.

BACKGROUND: Although research has identified a wide range of risk factors for suicidal behavior in prisoners, it does not establish who is most likely to act on their suicidal thoughts while incarcerated. METHODS: Self-report data were collected from a random sample of 1,203 adult men incarcerated across 15 prisons in Belgium, who represent 12% of all male prisoners nationwide. RESULTS: One-third (33%) of participants reported having suicidal thoughts during their incarceration, of whom 26% attempted suicide in prison (9% of all prisoners). Factors independently associated with suicide attempt among prisoners with suicidal ideation were violent offending (adjusted odds ratio [aOR] = 2.64, 95% confidence interval [CI] 1.33-5.23), in-prison drug use (aOR = 2.30, 95% CI 1.25-4.22), exposure to suicidal behavior (aOR = 1.96, 95% CI 1.04-3.68), and a lifetime history of nonsuicidal self-injury (aOR = 1.90, 95% CI 1.08-3.36). While related to suicidal thoughts, markers of psychiatric morbidity and aspects of the prison regime were not associated with the progression to suicide attempt. CONCLUSIONS: Many prisoners who think about suicide do not attempt suicide while incarcerated. Factors associated with suicidal ideation are distinct from those that govern the transition to suicidal behavior. Our findings lend support to the hypothesis that behavioral disinhibition might act as a catalyst in the translation of suicidal thoughts into action.

Crushed by the Belgian system: Lived experiences of forensic care trajectories by persons labelled as not criminally responsible.

BACKGROUND: Care trajectories of Persons labelled Not Criminally Responsible (PNCR) are often characterized by multiple transitions from one (forensic) mental health service to another and by long periods of admission. So far, little research has been conducted on forensic care trajectories, in particular on how PNCR perceive the trajectories they are subjected to. METHOD: Data were obtained via semi-structured interviews (N = 23) with PNCR in various (forensic) mental health services in Belgium. A maximum variation sampling strategy was applied to recruit a heterogeneous group of PNCR and inductive thematic analysis adopted to analyse the data. RESULTS: PNCR's experiences about care trajectories in Belgium are marked by an absent voice and passive position in the decision-making process in addition to a lack of support during transitions. Barriers for admission in (forensic) mental health services and the indeterminate duration of care trajectories contribute to overall negative lived experiences. CONCLUSION: Although some findings are interchangeable with general mental health care, PNCR's care trajectories differ by their undetermined nature, barriers for accessing care and power dynamics in compulsory forensic care. As concepts from prison sociology, such as tightness, power holders and pain of indeterminacy, seem to be equally relevant for the situation of PNCR, the balance between a criminal justice and mental health approach in forensic mental health care is questioned.

Linkage and continuity of care after release from prison: an evaluation of central registration points for drug users in Belgium.

PURPOSE: This paper aims to report the findings of an evaluation study concerning the Central Registration Points (CRPs) for drug users in Belgian prisons. CRPs support drug users to link with community-based services. DESIGN/METHODOLOGY/APPROACH: The study applied a multi-method approach that involved an exploratory literature review; a secondary analysis of the CRPs' databases; a qualitative study of the perceptions of a diverse sample of stakeholders with regard to the functioning of CRPs; and a prospective registration study. FINDINGS: One-third of the clients never attended an outpatient or residential substance abuse service before prison entry. This illustrates that the CRPs managed to reach clients who were not previously reached by (substance abuse) treatment services. All interviewed actors emphasized the added value of the CRPs in terms of informing, contacting, motivating and referring prisoners with a substance abuse problem. PRACTICAL IMPLICATIONS: Based on the research findings, two issues seem to be of paramount importance in the successful practice of CRPs: the confidentiality and specific expertise on (substance abuse) treatment. Given the complex situation of drug users in prison, an independent positioning and categorical assistance with drug-specific expertise seem to be essential. ORIGINALITY/VALUE: CRPs can be considered to be one of the "building blocks" that contribute to high-quality care and continuity of care for drugs users in detention.

The use of test instruments in forensic report writing - Explorative research in Flanders.

BACKGROUND: Forensic psychiatric reports have a profound impact on the life of a defendant, on society and on the mental health system. Good-quality reports are essential but are often criticized for their lack of thorough substantiation. The use of multiple methods to obtain information, test instruments (psychological and/or risk) and third-party information are recommended. STUDY PURPOSE: To explore the use of test instruments and third-party information, as part of a multi-method approach, in forensic psychiatric evaluations. We examined 151 court-ordered expert reports in Flanders (Belgium). RESULTS: A psychological test instrument was used in 61% of the cases, and a risk taxation instrument in 19% of the cases. Third-party information was used in 43% of the cases. CONCLUSIONS: A multi-method approach is not common practice in forensic psychiatric evaluations. The use of validated test instruments and third-party information can be improved. The quality of forensic reports could be improved by the establishment of a forensic observation centre and the use of a standardized approach.

A 17-Year National Study of Prison Suicides in Belgium.

BACKGROUND: Suicide is a leading cause of mortality in prisoners worldwide, yet empirical data on this matter are lacking in Belgium. AIMS: This study sought to describe characteristics associated with a consecutive series of suicides in Belgian prisons from 2000 to 2016 inclusive, in order to inform suicide prevention strategies. METHOD: All documented cases of suicide ( N = 262) were reviewed using a standardized assessment checklist. Official records were abstracted for prisoners' sociodemographic, criminological, and clinical information, as well as for suicide-related characteristics. RESULTS: Over the 17-year study period, suicides accounted for one third of all deaths in Belgian prisons. The average annual suicide rate in Belgium from 2000 to 2016 was 156.2 per 100,000 prisoners. Examination of all cases highlights both individual (psychiatric disorders and a history of suicide attempt) and situational (the early period of incarceration, interfacility transfers, and placement in solitary confinement) factors common in many prison suicides; some of them amenable to (clinical) management, which presents several potential avenues for suicide prevention. LIMITATIONS: Given the absence of a matched control group, no conclusions could be ascertained regarding risk factors. CONCLUSION: Suicide is a common, preventable cause of death among prisoners in Belgium. The results underscore the timely need for national standards and guidelines for suicide prevention in Belgian prisons.

How to overcome political and legal barriers to the implementation of a drug consumption room: an application of the policy agenda framework to the Belgian situation.

BACKGROUND: For more than 30 years, drug consumption rooms (DCRs) have been implemented in Western countries. DCRs are supported by a large body of evidence about public safety and public health effectiveness. However, a political consensus has never been achieved in Belgium on amending the existing law that explicitly penalises the supply of a room for facilitating drug use. Despite this adverse legal and policy framework, a DCR opened in the city of Liège in 2018. In this case report, we applied the theoretical framework proposed by Shiffman and Smith for policy agenda setting, in order to describe and assess how political and legal barriers were overcome in the process of opening the DCR. CASE PRESENTATION: For some years, fieldworkers and some city policymakers argued for DCR implementation in Belgium, but without gaining the support of the national authorities, mainly for ideological reasons. In order to address this debate, a feasibility study of DCR implementation in Belgian cities was commissioned. At the national level, an institutional debate took place about the political responsibility for DCRs as a public health intervention, as health care is mainly a matter of regional policy. The lack of consensus led to a situation of political deadlock. Meanwhile, the publication of the study report and the context of local elections offered an opportunity for Liège authorities to reignite the local debate on DCRs. At the local level, law enforcement, care professionals, residents, users, and the press were all involved in the implementation process. Therefore, a local consensus was formed and despite the absence of any national legal change, the DCR opened 1 month before the local elections. It has been working without major medical or legal incident since then. Incidentally, the mayor of Liège was re-elected. CONCLUSIONS: Although the lack of a legal framework may engender instability and affect longer-term effectiveness, the DCR implementation in Liège was successful and was based on a local consensus and effective communication rather than on an appropriate legal framework. The experience provides lessons for other cities that are considering opening a DCR despite an adverse legal and political context.

Risk Factors Associated With Inpatient Violence During Medium Security Treatment.

Violence is a common phenomenon both in regular and forensic psychiatric settings, and has a profound impact on staff and other patients. Insight into the individual risk factors associated with violence in forensic psychiatric settings is rare and is therefore the subject of this research. A retrospective file study in three medium security units in Flanders was conducted to compare non-violent inpatients with inpatients who engaged in (verbal and physical) violent behavior. Binary logistic regression analyses were used to examine which variables contributed independently to the risk of violence. The results showed that absconding during treatment was independently associated with physical violence. A personality disorder diagnosis and general non-compliance with treatment were associated with verbal violence. Both types of violence predicted early termination of treatment. Contrary to previous research, the results from the risk assessment tools were not associated with inpatient violence. Clinical implications are discussed and include, among others, that clinicians should remain vigilant for early warning signs of non-compliance during treatment.

Suicidal ideation while incarcerated: Prevalence and correlates in a large sample of male prisoners in Flanders, Belgium.

Prisoners constitute a high-risk group for suicide. As an early stage in the pathway leading to suicide, suicidal ideation represents an important target for prevention, yet research on this topic is scarce in general prison populations. Using a cross-sectional survey design, correlates of suicidal ideation while incarcerated were examined in a sample of 1203 male prisoners, randomly selected from 15 Flemish prisons. Overall, a lifetime history of suicidal ideation and attempts was endorsed by 43.1% and 20.3% of respondents, respectively. Approximately a quarter of all prisoners (23.7%) reported past-year suicidal ideation during their current incarceration, which was significantly associated with both imported vulnerabilities (psychiatric diagnoses and a history of attempted suicide) and variables unique to the prison experience (lack of working activity, exposure to suicidal behaviour by peers, and low levels of perceived autonomy, safety and social support) in the multivariate regression analysis. A first-ever period of imprisonment and a shorter length of incarceration (≤12months) were also associated with increased odds of recent suicidal ideation. Collectively, the current findings underscore the importance of both vulnerability factors and prison-specific stressors for suicidal ideation in prisoners, and hence the need for a multi-faceted approach to suicide prevention in custodial settings. In addition to the provision of appropriate mental health care, environmental interventions that target modifiable aspects of the prison regime could provide a substantial buffer for the onset and persistence of suicidal ideation in this at-risk population.

Economic consequences of legal and illegal drugs: The case of social costs in Belgium.

BACKGROUND: Legal and illegal drugs impose a considerable burden to the individual and to society. The misuse of addictive substances results in healthcare and law enforcement costs, loss of productivity and reduced quality of life. METHODS: A social cost study was conducted to estimate the substance-attributable costs of alcohol, tobacco, illegal drugs and psychoactive medication to Belgian society in 2012. The cost-of-illness framework with prevalence-based and human capital approach was applied. Three cost components were considered: direct, indirect and intangible costs related to substance misuse. RESULTS: The direct and indirect cost of addictive substances was estimated at 4.6 billion euros in Belgium (419 euros per capita or 1.19% of the GDP) and more than 515,000 healthy years are lost due to substance misuse. The Belgian social cost study reaffirms that alcohol and tobacco impose the highest cost to society compared to illegal drugs. Health problems are the main driver of the social cost of legal drugs. Law enforcement expenditure exceed the healthcare costs but only in the case of illegal drugs. CONCLUSION: Estimating social costs of addictive substances is complex because it is difficult to determine to what extent the societal harm is caused by substances. It can be argued that social cost studies take only a 'snapshot' of the monetary consequences of substance misuse. Nevertheless, the current study offers the most comprehensive analysis thus far of the social costs of substance misuse in Belgium.

Critical incidents and judicial response during medium security treatment.

This study examined inpatient incidents in three Flemish forensic medium security units and analyzed the subsequent judicial reactions to these incidents. During medium security treatment, incidents were reported for more than half of the participants. The most frequently registered incidents were non-violent in nature, such as absconding and treatment non-compliance. The base rate for physically violent incidents was low. Although crime-related incidents during medium security treatment were rarely prosecuted and adjudicated, the base rate of revocation - and hence drop-out from treatment - as a result of these incidents was high.