Risk Assessments in Forensic Psychiatry: Consequences and Experiences for Patients and Nurses

Abstract

In forensic psychiatry, risk assessment of future violence poses a great challenge to mental health care professionals. Forensic psychiatric patients are particularly vulnerable due to their complex mental health needs in combination with criminal behavior. The overall aim was to evaluate the importance and validity of risk assessments in forensic psychiatric care, and the related experiences of patients and nurses. The methods used were, (I) statistical analyses of file register data, (II) focus group interviews with nurses, (III) semi-structured interviews with inpatients, and (IV) quantitative analyses of assessments based on forensic psychiatric investigations. Findings: From a cohort of 125 forensic psychiatric inpatients, the findings showed a median length of stay of slightly more than two and a half years, predicted by previous contact with child- and adolescent psychiatry, violent index crime, psychotic disorders, history of substance use, and absconding during treatment. Treatment with special court supervision resulted in an almost five times longer length of stay compared to treatment without such supervision. Sixty percent were involved in at least one adverse event during their treatment. Elements of person-centered care were identified when nurses’ views were explored. Great efforts were made to confirm the unique person behind the patient, even when challenged by patients’ previous violence. Relationships with patients were considered crucial for successful risk management, this needed to be balanced against caring and restricting actions. The patients’ experiences of risk assessments could be summarized in three categories; taking responsibility for one’s own situation, taking charge of the present, and being involved and having impact. To evaluate the utility of the SAPROF (Structured Assessment of Protective Factors for violence risk), predictive validity was compared to three risk- and strength-based instruments: SAPROF, HCR-20 (Historical Clinical Risk Management-20), and LHA (Life History of Aggression). Only the SAPROF subscale ‘internal factors’ and the LHA total score, showed a significant, but weak, predictive ability of the occurrence of violent incidents. Conclusion: Perceived risk of future violence, as determined by the court, determined length of stay in forensic psychiatric care much more than clinical needs. However, structured instrument for risk assessments, currently used by clinician, showed poor ability to predict violence during inpatient care. Nurses in forensic psychiatric care found that risk assessments offered opportunities to confirm the patient as a person and to establish a trusting relationship. The findings point to the importance of promoting agency and active participation in the patients’ own care processes, highlighting the most important conditions for autonomy and well-being.