Patient wellbeing in forensic mental health: a systematic review of internalised stigma and an empirical qualitative study of the wellbeing of older people in secure forensic mental health wards in Scotland

Abstract

Background The world’s population is ageing and the proportion of older people in forensic mental health settings is growing. Stereotypical views of ageing and older people can be negative and lead to discrimination. Forensic mental health patients experience multiple stigmas which may impact on wellbeing. A better understanding of wellbeing and stigma in forensic mental health is needed. Aims The first chapter in this thesis aimed to systematically review literature to identify the consequences and correlates of internalised stigma in forensic mental health. The second chapter describes a qualitative exploration of the wellbeing of older people in forensic mental health inpatient settings, from the perspective of patients (older than 55 years) and staff. Methods In chapter one, nine bibliographic databases were systematically searched for forensic/criminal mental health studies reporting on a quantitative statistical relationship between a measure of internalised stigma and at least one other variable. 13 papers were quality assessed and the data was narratively synthesised. In chapter two, 10 inpatients (age 55+) from secure forensic mental health inpatient services were interviewed and 14 staff took part in focus groups about the wellbeing of older people in those settings. Using Grounded Theory Methodology, concurrent data collection and analysis led to the construction of a theoretical model of the wellbeing of older people in this setting. Results The systematic review of literature found that higher levels of internalised stigma were related to lower self-esteem, more severe symptoms of mental ill-health and having a prior history of homelessness and incarceration. Internalised stigma was found to be lower in those who had attended a peer support group, on average, compared to non-attendees. The empirical paper constructed a substantive theory of ‘Becoming a better person’ and the following core categories relevant to promoting wellbeing of older people: relationships, health, knowledge and skills, social context and interests. Conclusions No definitive conclusions can be drawn from the systematic review paper due to the heterogeneity of study designs, methods and measurement tools. However, findings were in line with that of a 2010 review and recommendations regarding future research are made, including the need for a specific tool to measure internalised stigma in a forensic mental health population. The empirical paper concluded that the older people wanted to re-engage with their sense of self and past skills and interests, as well as developing new skills. A values-based approach to wellbeing in older people was recommended to enhance wellbeing through values-consistent actions by staff and patients. The model itself was grounded in data which confirmed past literature around increasing health needs with age.