The three troubles of the triply troubled. Forensic perspectives on patients with a mental disorder, substance use disorder, and a history of violent crimes

Abstract

Patients in the forensic mental health services who suffer from a mental disorder, substance use disorder, and a high risk of violence are sometimes referred to as the "triply troubled". These patients have poor prognoses for both disorders and suffer heightened risks of relapse, criminal recidivism, and substance-related mortality. The overall aim of this thesis was to generate knowledge concerning the triply troubled patient group in order to better guide treatment development and improve patient outcomes. Study I explored clinic staff members' experiences with implementing clinical guidelines for substance use treatment in a high security forensic mental health service facility in Sweden. Interviews with staff at the start of implementation (N = 12) and one year later (N = 7) revealed the challenges with treating co-occurring disorders. Staff reported a division in attitudes regarding the legitimacy of substance use disorder, highlighting the underlying stigmatisation of the condition. Educational opportunities, sustained organisational support and motivation enhancing interventions emerged as important investments to facilitate tailored interventions for the heterogeneous patient group. In Study II person-oriented mixture modelling was used to investigate clinically relevant subgroups of patients. A three-step latent class analysis of patients’ (N = 98) primary mental disorders and substance use history identified four distinct patient types. Class 1 (42%) consisted of patients with a psychotic disorder, substance use disorder, and polysubstance use. Patients in class 2 (26%) also had a psychotic disorder but with cannabis-limited substance use. Class 3 (22%) was characterised by autism and almost no risk of substance use. Class 4 was the smallest class (10%) and was characterised by borderline personality disorder and polysubstance use. Both polysubstance use classes (1 and 4) had a significantly more extensive lifetime history of aggression, had an earlier age of onset of criminality and had a more extensive criminal past. The characteristics of these patient types suggest that co-occurring disorders cannot be treated as separate problems, and that treatment must be adapted to the severity of substance use and the specific mental disorder with which it co-occurs. Study III explored patients' experiences with co-occurring disorders and forensic treatment. An interpretative phenomenological analysis of interviews (N = 13) showed that the three troubles of the triply troubled are conceived of as expressions of a self-sustaining ecosystem often referred to as simply "it." Being enmeshed in "it" meant that substance use interventions would also have to target every other aspect of patients' lives with which substance use had become associated. Results suggest that forensic services are often considered rigid and overly focused on diagnoses with which patients do not fully agree. This thesis contributes to the empirical foundation for treatment development for co-occurring mental and substance use disorders in forensic mental health services. It offers insights from three perspectives: staff experiences, patient typology, and patient-reported experiences. These contributions have significant clinical implications for developing integrated, patient-centred treatment approaches for this complex patient group.