Identifying risk and protective factors in conditional release/discharge using systematic review and exploring lived experiences of compulsion and restriction orders using interpretative phenomenological analysis: a portfolio thesis in forensic mental health

Abstract

Compulsory treatment presents an ethical quandary and thus far research provides little promise regarding reduced readmission or length of inpatient stays, though some value has been shown in administering outpatient treatment. Those in forensic services and particularly those under restriction orders face the greatest constraints on their liberty with detention imposed “without limit of time”, unlike time-limited sentences in the prison system. There is a dearth of research exploring patients perspectives of compulsory treatment and particularly the most restrictive forms of this. The current study used interpretative phenomenological analysis to analyse interviews with participants about their experiences of living under restriction. Results derived four superordinate themes; (1) How did I end up here? (2) Impact: Power, Punishment and Protection (3) Surviving and Adapting (4) Healing. The results are reviewed in the context of extant findings; clinical implications and areas of future research are discussed. Conditional release (CR) is the primary mechanism for managing individuals under forensic care in the community. Services must identify those at higher risk for revocation/ readmission (RR) and promote protective factors for increased quality of life and to minimize recidivism. A systematic search was conducted to identify, summarise and critically assess studies that have evaluated factors associated with RR in forensic patients. The review found that higher substance use, personality disorder/ traits, severity and chronicity in psychiatric illness, criminality and minority ethnicity are risk factors for RR. Protective factors identified were: white ethnicity, being married, social security, not having personality disorder, longer tenure in outpatient programme, clozapine treatment, fewer incidents while on CR, labour skills and higher functioning at CR. Future research should include prospective study designs, standardised measures, and variables independent from RR. Clinical implications include identification of individuals with risk factors for RR and promotion of protective factors.