“What if you listened to and involved the caregivers?” ‒ Experiences and needs amongst caregivers involved with mentally disordered offenders and mental health services

Background and objectivesOver the past 20 years, the number of mentally disordered offenders (MDOs) has increased intensively in Denmark. Consequently, the number of caregivers, families and network involved with MDOs has also increased. Despite a heightened political focus on the involvement of caregivers as an important part of the patient pathway and recovery processes, knowledge of caregivers’ experiences is very limited. The aim of this study is to illuminate experiences and needs amongst caregivers taking care of MDOs in Denmark.MethodsThe study is based on semi-structured interviews with caregivers. The content of the interviews is analysed using content and textual analysis focusing on identifying patterns and themes.ResultsCaregivers involved with MDOs perform various roles and tasks from practical support to acting as case managers. These tasks tend to put a remarkable pressure and challenges on caregivers. Furthermore, caregivers experience emotional stress such as loneliness, shame, sorrow and feelings of inadequacy. Caregivers spend a lot of time establishing sustainable narratives about mental illness and offences, in order to reduce stigma and come to terms with chaotic and extraordinary incidents, and they play an important role as carriers of hope on behalf of the patients to support processes of personal recovery.ConclusionThe majority of caregivers in this study share a fundamental experience of neither having achieved sufficient support in the trajectories leading up to the forensic debut nor being involved or receiving enough and dedicated information while the often long-term sentences to treatment or placement are ongoing. (AU)

Effects of Implementing the Short-Term Assessment of Risk and Treatability for Mechanical Restraint in a Forensic Male Population: A Stepped-Wedge, Cluster-Randomized Design.

The assessment and formulation of the risk of violence and other unwanted behaviors at forensic psychiatric facilities have been attempted for decades. Structured professional judgment tools, such as the Short-Term Assessment of Risk and Treatability (START), are among the recent attempts to overcome the challenge of accomplishing these goals. This study examined the effect of implementing START in clinical practice for the most serious adverse events among the target group of severely mentally ill forensic psychiatric inpatients. Results were based on the use of mechanical restraints as an outcome. This study is a pragmatic, stepped-wedge, cluster-randomized controlled trial and was conducted over 5 years. It included eight forensic psychiatric units. Fifty out of 156 patients who had a basic aggression score of more than 0 were included in the study. We found that the rate of mechanical restraint use within the START period were 82% [relative risk (RR) = 0.18], lower than those outside of the START period. Patients evaluated within the START period were also found to have a 36% (RR = 0.64) lower risk of having higher Brøset Violence Checklist scores than patients evaluated outside the START period. Previous studies on START have primarily focused on validation, the predictive capability of the assessment, and implementation. We were only able to identify one study that aimed to identify the benefits and outcomes of START in a forensic setting. This study showed a significant reduction in the chance for inpatients in a forensic psychiatric facility to become mechanically restrained during periods where the START was used as risk assessment.

Offender Recovery. Forensic Patient Perspectives on Long-Term Personal Recovery Processes.

Knowledge on user experiences from mentally disordered offenders (MDOs) is still limited in a Danish context, especially regarding recovery from offences, severe mental illness, long-term admissions and often involuntarily contact with hospital psychiatry. The study is based on 34 semi-structured interviews with nine forensic patients exploring their experiences with personal recovery processes. The MDOs point out a significant number of elements and factors enhancing, supporting and limiting personal recovery processes. Long-term recovery processes for MDOs involve coming to terms with mental disorders as well as offences. Working with offender recovery implies addressing and understanding the index offence leading to psychiatric measurement as well as addressing risk and prevention of future crime. This coming to terms is an individual and deeply personal process and it often involves several and changing narratives. According to the informants, professionals play a crucial role in supporting recovery processes and maintaining hope and optimism over time. MDOs experience structural barriers limiting recovery potential, especially stigma or limited areas of participation. It is important not to focus solely on personal recovery as a one-dimensional individual process or responsibility, but as a process also marked by structural and organisational challenges.

Patients' perspectives on three-monthly administration of antipsychotic treatment with paliperidone palmitate - a qualitative interview study.

INTRODUCTION: Three-monthly dosage of paliperidone palmitate entails longer time to relapse after discontinuation, is similarly tolerable and safe compared to monthly injections of paliperidone palmitate and is beneficial for the caregivers. However, few studies have so far explored in depth the patients' experiences with paliperidone palmitate medication every three months, or with switching from monthly to three-monthly injections of paliperidone palmitate. MATERIAL AND METHODS: A qualitative study based on individual interviews with persons with schizophrenia who receive three-monthly paliperidone palmitate in Norway, Sweden and Denmark. Data was analysed according to qualitative content analysis. RESULTS: Twenty-four patients, 16 men and 8 women, took part in individual interviews. The patients' mental health care professionals mainly recommended the switch to three-monthly paliperidone palmitate, and few or no disadvantages were described. According to the patients, three-monthly paliperidone palmitate had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the participants described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine 'wore off' before the next injection. According to the patients, switching to three-monthly paliperidone palmitate did not influence the frequency or content of patients' interaction with health care professionals. CONCLUSION: Switching from monthly to three-monthly injections with paliperidone palmitate seems to be experienced as advantageous for patients with schizophrenia.

"I live, I don't work, but I live a very normal life"-A qualitative interview study of Scandinavian user experiences of schizophrenia, antipsychotic medication, and personal recovery processes.

PURPOSE: To illuminate user experiences of schizophrenia, reasons for receiving antipsychotic medication, and encounters with mental health services. DESIGN AND METHODS: 24 semistructured qualitative research interviews with schizophrenia patients treated with 3-monthly paliperidone palmitate across Scandinavia were synthesized in qualitative content analysis. FINDINGS: Participants describe considerable challenges in everyday functioning. Simultaneously, they rate their current mental and physical well-being high and seem satisfied with their lives. These pathways indicate personal recovery. PRACTICE IMPLICATIONS: The participants emphasize the importance of trustful relations with healthcare professionals, therapeutic conversations, antipsychotic medication in a 3-monthly formulation, and support from relatives.

'First and foremost a human being ': user perspectives on mental health services from 50 mentally disordered offenders.

BACKGROUND: This is the first study of this kind in a Danish context. Knowledge and research on user perspectives is rather limited in Danish as well as Nordic psychiatry. AIMS: The aim of the study was to create new knowledge on patient and user perspectives and how mentally disordered offenders perceive their hopes and expectancies as well as their interactions with staff in mental health services. Furthermore, the aim was to establish what constitutes helpful care and treatment seen from a user perspective, and how the users themselves look at and perceive their sentences and how, according to them, the overall aim to prevent future crime can be fulfilled. METHOD: The study is based on 50 semi-structured qualitative research interviews. Main themes and patterns were condensed and synthesized in a qualitative analysis. RESULTS: The study has provided useful knowledge of service users' experiences with nursing, treatment and rehabilitation practices. As part of the interviews, patients were asked to contribute with advice on how to improve practices within mental health services. There are remarkable similarities between the answers, and central points were reiterated from interview to interview: The importance of mental health staff acting with respect and empathy in their interaction with patients, improved communication between patients and professionals involved in clinical pathways, responsiveness and shared decision-making when adjusting medical treatment as well as a greater variety of activities offered within inpatient units. CONCLUSION: When asked what it is like to be a forensic patient, the informants underline that despite severe mental illness, social marginalization as well as various criminal records they are still, first and foremost, human beings. However, they often feel dehumanized and monstrous.

A Thorn in the Flesh? Forensic Inpatients in General Psychiatry.

PURPOSE: To illuminate whether and how taking care of forensic inpatients is experienced as a burden among staff and managers in general psychiatry. DESIGN AND METHODS: Qualitative analytical strategies based on interviews and questionnaires. FINDINGS: The interplay between physical environment, bottlenecks, poor information exchange, lack of knowledge and competences, complex psychopathology, and a vague and therefore uncomfortable task of nursing leads to a focus on criminal offenses rather than mental disorders and an increased risk of brutalization and stigmatization in nursing practices. Members of staff identify the care of mentally disordered offenders in general psychiatric units as either "a parking space" or a very difficult or frightening course, where staff members tend to behave like pleasers in order to avoid risks of conflict or physical violence. Either way, it seems hard to provide sufficient mental health care. PRACTICE IMPLICATIONS: Nationwide training and teaching as well as knowledge exchange between specialized forensic psychiatry and general psychiatry are recommended. Further exploration is needed on patient perspectives and on avenues to increase efficiency and decrease bottlenecks throughout the clinical pathways. Furthermore, we need additional knowledge of the impact on general patient populations' resources for treatment and their safety.

Encountering hysteria: doctors' and patients' perspectives on hysteria in Denmark, 1875-1918.

The history of hysteria stretches over several millennia and contains a plethora of different understandings and interpretations. This paper focuses on a central part of its Danish history, from the last decades of the nineteenth-century 'age of nervousness' until the end of World War I. It is argued that the understanding and negotiation of hysteria and its explanations took place in a complex interaction between doctors and their patients. Whereas the psychiatrists during this period moved towards an understanding of hysteria as a functional disorder, the patients, of whom approximately one-third were male, maintained that their illness was of somatic origin, and closely related to social, economic and working conditions.

On unsafe ground: the practices and institutionalization of Danish psychiatry, 1850-1920.

The aim of this paper is to characterize the efforts of late nineteenth-century Danish psychiatrists to have their field recognized as a discipline in its own right, and their fight to be accepted as practitioners of science, following common scientific standards of exactness and proof. This struggle took place on two fronts: with colleagues in the somatic branches of medicine, and also with lay people and the general public. According to the psychiatrists, laymen persistently contested psychiatry's legitimacy in diagnosing and treating mentally ill patients. Criticism of its scientific objectivity made it difficult for psychiatry to gain respect on an equal footing with other branches of medicine.