Looking beyond the illness: forensic service users' perceptions of rehabilitation.

539764 research-article2014

JIVXXX10.1177/0886260514539764Journal of Interpersonal ViolenceBarnao et al.

Article

Looking Beyond the Illness: Forensic Service Users’ Perceptions of Rehabilitation

Journal of Interpersonal Violence 2015, Vol. 30(6) 1025–1045 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514539764 jiv.sagepub.com

Mary Barnao, MA,1 Tony Ward, PhD,2 and Sharon Casey, PhD1

Abstract The aim of this qualitative study was to explore perspectives on rehabilitation of those detained in a New Zealand forensic hospital setting. Twenty forensic service users participated in individual interviews, which were audio-taped, transcribed verbatim, and subjected to thematic analysis. The analysis identified seven themes that were broadly categorized into those that concerned the rehabilitation context (external) and those that more directly reflected the forensic service user’s personal experience (internal). External themes highlighted a person-centered approach, the nature of relationships with staff, consistency of care, and awareness of the rehabilitation pathway. Internal themes related to forensic service users’ self-evaluations, agency, and coping strategies. These findings are discussed within the broader context in which rehabilitation took place. Keywords forensic mental health, rehabilitation, service users’ perspectives, thematic analysis

1Deakin

University, Melbourne, Australia University of Wellington, New Zealand

2Victoria

Corresponding Author: Tony Ward, School of Psychology, Victoria University of Wellington, P.O. Box 600, Wellington 6037, New Zealand. Email: [email protected]

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Introduction There has been a growing focus on rehabilitation in forensic mental health over the past decade or two (Mullen, 2000). The dual imperatives of caring for the person and managing risk have seen practitioners attempt to blend elements of psychopathology and risk paradigms into rehabilitative services (Robertson, Barnao, & Ward, 2011). Furthermore, newer, patient-centered approaches that have been used in general mental health settings, such as the recovery model, have started to be introduced into forensic settings (Drennan & Alred, 2012). However, the development of theories to guide service development and evaluation has not kept pace with the interest in rehabilitation and recovery (Blackburn, 2004). There is a paucity of research examining how the people who use forensic mental health services perceive rehabilitation and other aspects of their care (Coffey, 2006). This is unfortunate as understanding their perceptions of services is critical for effective service provision and integral to the process of engaging this complex, long-stay population (Carlin, Gudjonsson, & Yates, 2005). Nonetheless, some general conclusions can be drawn from the available literature. First, therapeutic relationships appear to be at the core of the treatment process for forensic service users detained in secure facilities (Ford, Sweeney, & Farrington, 1999; Mason & Adler, 2012; Mezey, Kavuma, Turton, Demetriou, & Wright, 2010; Schafer & Peternelj-Taylor, 2003; Vaughan & Stevenson, 2002) and the quality of these relationships is related to satisfaction with services (Bressington, Stewart, Beer, & MacInnes, 2011). Second, detained forensic service users are concerned about the disempowering nature of restrictions on their liberty (Byrt & Reece, 1999; Morrison, Burnard, & Phillips, 1996) that are often experienced as punitive (Hinsby & Baker, 2004). Third, forensic service users highlight a number of problems in the rehabilitation process including being unaware of their care plans, feeling insufficiently prepared for discharge, and having restricted opportunities to be active outside of therapeutic programs (Craik et al., 2010; Farnworth, Nikitin, & Fossey, 2004; Ford et al., 1999; Morrison et al., 1996; Skelly, 1994).

The Present Study To date, there has been no detailed examination of detained forensic service users’ experiences of their entire rehabilitation experience, both within and beyond therapeutic programs. The present study uses a phenomenological methodology to explore the lived experiences of a group of service users undergoing rehabilitation within a New Zealand forensic hospital. The research was


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designed to understand the key issues regarding rehabilitation from the perspective of service users to inform service development. It takes a position that reality is constructed by and between the persons who experience it, is necessarily contextual, and can differ between people based on their unique understandings of the world and their experiences of it (Berger & Luckmann, 1966). Thus, the epistemological perspective adopted is that of constructionism. The design of the interview protocol that sought to identify participants’ perspectives on the rehabilitation process drew on previous work outlining the features of a sound rehabilitation theory (Ward & Maruna, 2007) and its application to forensic rehabilitation (Robertson et al., 2011).

Method Setting The forensic service examined in this study was developed on the site of a large psychiatric hospital. Although the hospital was closed following a move to community-based care, some of the staff who had previously worked in the hospital were subsequently employed in the new forensic and rehabilitation service. Participants were recruited from three inpatient units and several cottages of the forensic service. The inpatient units comprised a male only medium secure forensic intake ward; a mixed gender medium secure forensic ward comprising both new admissions and males who had progressed from the intake ward; and an open rehabilitation ward that has a combination of forensic and general mental health service users with severe and enduring mental illnesses. The cottages, which are also on the hospital campus, house one to four people. Forensic service users typically progress from secure settings to “step-down” beds in the rehabilitation ward and cottages before transitioning back into the community. The forensic population, from which the participants were drawn, predominantly comprised special patients who had been acquitted of serious offenses on the grounds of insanity or who had been found unfit to stand trial. Prisoners requiring mental health care in a secure hospital setting, individuals remanded in hospital for court-ordered assessments of insanity and fitness issues, and those pending trial were also represented, though in much smaller numbers.

Participants Clinical psychologists and/or psychiatrists working in the wards and cottages outlined above were asked to identify potential participants for the study.


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Service users were eligible to participate if they could communicate in English, had been an inpatient within the service for a minimum of 6 months, and were assessed by their psychiatrist and/or psychologist to have a relatively stable mental state. The assessment of individuals’ current level of psychological functioning occurred during routine consultations, which included a mental status examination. Those who met the selection criteria were given a brief verbal explanation about the study by one of the clinical psychologists working in their unit and provided with an information sheet that they were encouraged to discuss with a trusted staff member, friend, or member of their family. Individuals wishing to volunteer for the study were asked to contact the researcher directly or to arrange an interview time through the clinical psychologist on their ward. Prior to conducting the interview, confidentiality and anonymity were discussed, areas of misunderstanding were identified and clarified, and participants signed a consent form. All participants were given a $20 store voucher in recognition of their time and contribution to the research. Seventy-four percent of detained forensic service users who met the inclusion criteria agreed to participate in the study (20/27 patients). The sample comprised 20 service users, ranging in age from 27 to 74 (M = 44.2, SD = 11.61), who were drawn from all areas of the forensic inpatient service. Most of the participants (15) were special patients who had been acquitted of their offenses on the grounds of insanity or who had been found unfit to stand trial. Seventeen participants were men and three were female. Ten participants identified as having Maori ancestry (indigenous New Zealanders),1 four were of Pacific Island or mixed Pacific Island/Maori descent, and the remaining 6 were European. The participants’ length of stay within the service ranged from 6 months to 12 years with an average of 2 years and 4 months. Four participants had previous admissions to the same service and two had been transferred from forensic services in other parts of the country. The majority (17) had admissions to mental health services prior to their index offense and many had longstanding psychiatric histories. The most prevalent index offenses were murder, attempted murder, arson, and wounding with intent to cause grievous bodily harm; several of the participants had been charged with multiple offenses. Almost half of the participants had a prior criminal history and some had spent time in prison. The majority of participants had been diagnosed with schizophrenia or other major mental disorders (e.g., bipolar disorder, schizoaffective disorder, psychosis not otherwise specified), most had coexisting alcohol and/or substance abuse or dependence, and many had attracted other diagnoses including posttraumatic stress disorder, depression, and personality disorders (antisocial, borderline, dependent). Two participants had a history of head injury. Participants’ educational level ranged from


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1 year at high school to university-level education, with most lacking any formal qualifications. Ethical approval for this study was obtained from the Deakin University Human Research Ethics Committee and the Central Regional Ethics Committee in New Zealand.

Design and Data Collection A semi-structured interview protocol was developed and used to explore forensic service users perspectives on rehabilitation, both within and beyond therapeutic programs, in single, face-to-face interviews. The interview protocol was developed in consultation with forensic mental health practitioners and consumer advisors employed by the service and piloted on two forensic service users. Consistent with a phenomenological approach, questions were open-ended with follow-up discussion led by the participant rather than the researcher (Laverty, 2003). The term rehabilitation was not defined extensively for the participants, allowing for an open forum where any relevant issues could be discussed. Interview questions covered the following domains: awareness of the aims of rehabilitation; utility of different aspects of rehabilitation; understanding of reasons for offending; staff treatment; emphasis on strengths, risk, and mental illness; and service responsiveness to activities, experiences, and resources associated with wellbeing. Some examples of questions from the interview protocol are as follows: “How has talking to your treatment team helped you to understand why you’re here?” “What is your understanding of what you need to do to make enough progress in hospital to return to living in the community?” “How do staff treat you?” A copy of the semi-structured interview can be obtained from the lead author on request. The interviews were audio-taped and transcribed verbatim. The interviews varied in length from 20 min to 65 min with an average duration of 51 min including time for debriefing. Data collection occurred over an 8-month period. The socio-demographic, medico-legal, and diagnostic data were gathered from participants’ files.

Reflexivity The approach adopted in the study was one aimed at engendering confidence and creating rapport that allowed clients to talk openly and honestly about their rehabilitation experiences (Willig, 2008). However, the authors acknowledge that a dynamic interplay occurs between the researcher and the participants. What this means is that the researchers’ beliefs and experiences with respect to the rehabilitation process will influence the data


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analysis process (Alvesson & Sköldberg, 2000). The lead author, who holds an overarching social constructionist theoretical perspective that contributed to the research design, is employed as a clinician by the hospital where the research was conducted. Although she is not directly involved with the clients interviewed, it is acknowledged that this role has the potential to influence how the data could be interpreted. Although the second and third authors have no relationship with the organization that is the subject of this research, both have experience with similar institutions. To account for potential subjectivities, the research team ensured that there was a high level of agreement in the analysis process.

Data Analysis Thematic analysis was undertaken to identify key themes and patterns in the data. The primary analysis was performed by the lead author (M.B.) based on the method outlined by Braun and Clarke (2006, p. 87): familiarization with the data, through reading and re-reading the content; generating initial codes (units of meaning) for the data; developing themes inductively from the data (themes were groups of words with similar meaning on the basis of patterns/ commonalities of reported experiences); reviewing and refining themes to ensure that allocated text for each theme was relevant (theme naming); and defining and naming themes (identifying the “essence” of what each theme is about and determining clearly what aspect of the data each theme captures). The primary analysis was carried out in two phases. Phase 1 was concerned with the derivation of themes and involved all transcripts being read and coded line by line. A hierarchical structure of themes was subsequently produced. In Phase 2, the prevalence of these themes was examined across the entire sample. Prevalence ratings were arrived at by calculating the percentage of participants for whom the theme appeared at least once in their interview transcript. Prevalence ratings ranged from 70% to 100%. The final stage of analysis involved the first researcher and an independent researcher reviewing a sample (25%) of randomly selected transcripts to check on agreement with theme identification. The independent rater was given a list of the themes and was required to make a decision about their presence or absence in each of the transcripts. This revealed a high level of agreement between the two raters (κ = .92).

Results The analysis identified seven themes that were broadly categorized into those that were external to the forensic service user and in a sense provided the


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rehabilitation backdrop or context, and those that more directly reflected his or her personal experience (internal).

External Themes The four external themes derived from an analysis of the interviews after were person-centered approach, nature of relationships with staff, consistency of care, and awareness of rehabilitation pathway. Person-centered approach: “Being at center stage.” A key consideration in participants’ accounts was the degree to which the person was placed at the center of a rehabilitation plan. From the participants’ perspective, this meant that staff knew what mattered to them, acted on this information where possible, and worked collaboratively with them to support change. Although several participants described a range of person-centered practices such as staff listening to their concerns, helping them to make contact with loved ones, and supporting their interests, in general there was not a strong perception of a person-centered approach. This could be seen in the decision-making process where participants perceived consultation, rather than collaboration, to be the norm. Some participants considered that they were “told” what they needed to do and many felt coerced to comply with therapeutic programs to progress through the service. As participants did not consider themselves to be at the center of decision-making, they often experienced some disconnection between their therapeutic programs and their perceived needs. Although most reported benefiting from some of their programs, it was not uncommon for other programs to be perceived as irrelevant or not well matched to their personal characteristics (e.g., intelligence). Participants sometimes felt that they were slotted into existing programs or services rather than the interventions being individually tailored to meet their needs: There is a cookie cutter kind of mentality where as long as you tick A, B, and C boxes everything should be alright . . . but there is not so much of a kind of tailor-made response. . . . There are areas of my care which are just kind of, they are non-negotiable and there is no sense of partnership and participation for me. . . . They are stuck in a kind of system that doesn’t give them any scope to really think outside of the square and help me with some of my more out of the norm kind of ideas and needs.

Participants’ perceptions of service delivery reflected a traditional, medical model in which power is invested in professionals, particularly doctors:


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Yes [nurse] will come in and explain the situation. Whatever happens he will say, “Oh well, do it this way and then I will talk to the doctor and then I will come back and tell you what he has decided.”

Participants described a range of institutional practices that they considered undermined their individuality. One example was queuing for medication, which some participants found dehumanizing: They sort of have moments when they don’t have respect, you know, treat you like a lot of cattle, picking up meds and stuff.

However, such practices were by no means universal. Several participants drew a distinction between the “old guard,” whom they thought had transferred “bad habits” from the psychiatric hospital where they were previously employed, and some of the newer staff whose practice was perceived to be informed by contemporary approaches to mental health care. Nature of relationships with staff: “Being treated as a real person with feelings.” Participants’ accounts highlighted the immense importance of therapeutic relationships in their care.2 The determining factor in participants’ evaluation of their relationships with staff was the degree to which they felt they were treated as people. This was reflected in the staff attributes and behavior that they considered essential for building therapeutic relationships. Almost all of the participants highlighted the fundamental importance of respect. Interest in the person, which included taking the time to talk and listen, acceptance, understanding, empathy, emotional support, and praise and encouragement, also featured strongly in participants’ views about the essential features of therapeutic relationships. Participants’ accounts suggested that the quality of therapeutic relationships was variable. Over half of the participants (12) were predominantly negative in their evaluation of therapeutic relationships, almost a third (6) were predominantly positive, and the remainder (2) were neither positive nor negative. Most participants reported experiences with both “good” and “bad” staff and even those who were most dissatisfied with their therapeutic relationships could identify at least one or two people to whom they related well. These staff were perceived to “have a heart” and to take a personal interest in participants: They are genuine in their approach and they are genuine in their “How is life for you at this time? What do you hope to be doing in five or three years’ time? Where do you see yourself progressing? What can they do to assist?”


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Participants’ reports suggested that the greatest barrier to understanding them as people was a disproportionate focus on mental illness and, to a lesser degree, risk of reoffending. Several participants considered that staff defined them in terms of their illness and felt that they were “treated as a diagnosis rather than a person.” Members of this group expressed fears that their behavior would be misinterpreted as evidence of mental illness, that they would be seen as unreliable or irrational in their accounts, and that their aspirations would be dismissed as unrealistic or even grandiose. More generally, participants thought that being seen in terms of their illness and risk focused staff attention on their deficits, accentuated the differences between themselves and the staff, and created an “us and them” mentality: Then there is kind of the idea that we are mad and bad at the same time, we are not normal and so that is a barrier perhaps between staff members relating to us as people like themselves.

Consistency of care:“Singing from the same hymn book.” Participants’ narratives highlighted the significance that they placed on a consistent approach to their care. From their perspective, consistency provided a much-needed sense of control, security, and predictability over their lives. There was fairly widespread reporting of concerns about variability and inconsistency of care. One aspect related to the high rate of staff changes that participants saw as an impediment to the development and maintenance of therapeutic relationships. Some felt that there was little to be gained in engaging with staff who were likely to be transient and chose not to engage with them at all. Others, who had got to know and trust certain staff members, were frustrated when they left the service or were rotated: I talk to my keyworker now and then. It has just changed . . . I had [nurse] and we talk quite a bit still about things. I find I got a good rapport—that is another thing that bugs me about the place—you get a good rapport with someone and then they change it on you again.

Another commonly expressed source of dissatisfaction concerned the lack of a cohesive and united approach to rehabilitation. Some participants reported discrepancies between what they had been told would happen and what actually transpired (e.g., estimated time frames for placement in different units, transfers to different services). Inconsistencies in care were often perceived to reflect divergent professional opinions, approaches, and philosophies on issues such as the management of misdemeanors, matters of diagnosis and


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risk, and rehabilitation trajectories and plans. From participants’ perspective, such inconsistency heightened their sense of powerlessness and created confusion and frustration. The perception that professional decision-making was sometimes arbitrary, combined with an awareness of the profound impact it could have over their lives, also led participants to feel vulnerable: Every doctor has a different opinion, you know what I mean. You get a new doctor; it can mean the difference of getting out or staying here for ten years.

However, when professionals were united in their approach to participants’ care, such as when the treatment team were “all singing from the same hymn book,” participants felt confident and optimistic: The team thing is really, really important because it’s more witnesses to you, who you are and your whole being instead of just one person saying, “Oh yeah, you’re right or wrong, you’ve done well.” You have the perspective of five different health care professionals . . . and when they are all singing from the same hymn book you know that your attitude and your involvement is a positive and a good way forward kind of thing . . . it makes you more positive about what you are doing.

Awareness of rehabilitation pathway: “Knowing where you are going.” Being clear about the aims of one’s rehabilitation and the steps that are required to achieve them are essential if individuals are to experience some control over their lives and hope for the future. However, participants’ accounts suggested widespread confusion about their rehabilitation pathway: So I am actually just going forward but not knowing where I am going. I don’t know where this programme is taking me . . .

Participants expressed a range of views about what they thought was required for progression and eventual release. Some believed that moving forward would be determined by their treatment team or doctor and that they had little ability to influence their progression. Others viewed rehabilitation as an indeterminate sentence in which release was dependent on the passing of time. However, not all participants felt powerless. Many reported taking steps that had been recommended to them by their treatment team to facilitate their progress (e.g., learning about their illness, taking medication, doing programs, seeing a psychologist, getting a job). Although some participants could see the intrinsic value in what they were doing, others appeared to be primarily motivated by a desire to do what was required to “get out.”


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However, compliance did not always guarantee progression and participants were disillusioned and frustrated when they failed to advance despite doing what they thought was expected of them: I have done everything they have asked me, everything, and I still got nowhere.

Staying out of trouble was a salient consideration in moving forward for several participants who had experienced negative repercussions for misdemeanors and breaches of service policies. One participant summed up what he thought was required of him in the following way: Just like behaving, keeping hard out doing what you are not supposed to be doing like alcohol, herbals, abusive language and just being cheeky to other clients . . . I’ve got it written on a plan.

Internal Themes The three internal themes derived from an analysis of the interviews were: self-evaluation, agency, and coping strategies. Self-evaluation: “What you are, where you are from, what you are about.” Participants’ self-perceptions appeared to be strongly influenced by their role as forensic patients. In particular, their narratives generally contained many allusions to mental illness. They referred to themselves as sick, or alternately well; used psychiatric diagnoses and terminology when talking about themselves; and emphasized the importance of taking their medication: . . . the meds do help . . . with my troubles. It does help and it is good that I learn about the need for medication, how important it is to continue after I leave hospital . . . I am one of those that know that I have got to take medication for the rest of my life. I had a serious breakdown so I understand why the medication is important.

Other aspects of participants’ identity, including culture, interests, and work, were also mentioned. Their accounts gave glimpses of who they were as people, what was important to them in their lives, and, occasionally, their hopes and dreams for the future. However, these aspects were generally less salient than issues relating to mental illness and other problems. Few spontaneously mentioned any strengths and capabilities (although some volunteered a range of perceived deficits) and some had difficulty identifying positive attributes even when directly asked about them.


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Perhaps in an attempt to fight the loss of identity associated with the patient role, some participants reported challenging “the system” over issues related to their mental disorder. Those who were at variance with staff over their diagnoses and psychiatric treatment reported often feeling invalidated, discredited, and sometimes also blamed for their “lack of insight.” However, participants who accepted that they were mentally unwell were inclined to see themselves as unable to trust their own judgment and dependent on staff for decisions about their treatment: I just want them to make the right decisions for me because they know better than I do, they know their job, they do.

Some participants’ narratives suggested that their identities were not only underdeveloped but also incorporated a range of negative self-perceptions. These were often based on feelings of culpability for their offending despite having been acquitted on the grounds of insanity. They regarded themselves as bad, unworthy, or needing to be “absolved” for their offending. Participants who perceived themselves in this way often had modest expectations of the service: I don’t expect too much. I’m in here because I beat this guy up. I have to remember that. When I want things or when I feel as though I’m being left out or anything I have to remember that I committed a crime.

Agency: “Managing your own life.” Having a sense of control over one’s life circumstances is generally regarded as important for happiness and positive mental health. However, a lack of control overshadowed participants’ experience of compulsory detention in an institutional environment. Unsurprisingly, this was greatest for participants who were detained in secure wards, particularly those who had not yet been granted any leave. These participants reported restrictions on all manner of freedom that are normally taken for granted: I can’t choose my clothes, I can’t choose what hours I keep for sleeping— within reason there is some flexibility—I can’t choose the food I eat except for once a month. There is some choice but once again it is within what the hospital allows. So really pretty much everything is controlled to some degree . . . all those kind of big things that people might take for granted, walking down to the dairy [cornerstore] and so on, I’m restricted and controlled in all sorts of ways.

For some participants, the restrictions on their freedom were an incontrovertible fact and a few stated they were grateful for the limited choices


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available to them. However, most seemed to struggle with the loss of liberty that was variously described as being “dictated to,” “locked down,” and “living in captivity.” Some expressed feelings of sadness, vulnerability, or despair, whereas others reported feeling resentful, frustrated, or even outraged about their powerlessness. For a number of participants institutional control was underlined by a sense of being constantly monitored and the knowledge that observations about them would be recorded in the clinical notes. Others considered that the potentially life-long supervision attached to being a special patient was unwarranted and feared that they might never be permitted any independence over their lives: I don’t know, I could be a special patient for the rest of my life. I might never get that acknowledgment that I can manage my illness and go down to the pharmacy and take my meds, and turn up for my blood tests and appointments, I may never get that. I think that is super scrutiny to the max, I think that is a bit of over-kill really.

Coping strategies: “Adapting to the environment.” Participants reported a wide range of strategies for dealing with their loss of agency. Their coping styles fell into two general categories: passive (compliance and disengagement) and active (problem-focused and emotion-focused coping). Participants were about equally divided in the use of passive and active strategies (14 and 13, respectively) with almost half using a combination of both. The most common passive response, described by half of the participants, was compliance. Participants who adopted a compliant approach reported doing what they thought was expected of them by those in authority (e.g., attending programs, abiding by the rules) or even exceeding perceived expectations (e.g., volunteering for domestic tasks). They considered that suppressing their frustration about their powerless position, cooperating with staff, and adhering to service policies would make institutional life more bearable and hasten their release: . . . some [staff] give me some helpful kind of ideas to perhaps shorten the length of my stay here and I guess it all comes down to . . . playing the game people talk about. With say cannabis for example, or herbal highs or whatever, I am not going to get anywhere if I was to get cannabis or herbals in here.

Disengagement was another form of passive coping and participants described using this approach when they mistrusted staff or felt aggrieved by them. Those who used this approach reported a variety of ways in which they distanced themselves from staff such as choosing not to share their feelings


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and concerns with them, retreating to their bedrooms when possible, avoiding eye contact, and using iPods to discourage staff from communicating with them. Relationships with staff were generally regarded as superficial and participants reported approaching staff only when necessary to meet practical needs. Participants also described a range of active ways of coping with life in the forensic hospital. Those who used problem-focused coping strategies perceived that there were at least some aspects of their situation in which they could take action to reduce stress or exercise some control over their lives. Some participants outlined how they had independently formulated goals for themselves in areas such as study, recreation, and work before making judicious approaches to certain staff for assistance and resources. Others regarded community meetings as a useful forum for raising issues and requesting change: We have a meeting every Friday, where we bring up issues, general business, complaints and things like . . . just recently . . . we used to have bacon every morning for breakfast, one of the guys bought it up that we should have a change. As much to the dislike of some of the staff, we got the change.

Although participants considered that there were some actions they could take to improve their lives, they were aware that there were many aspects of their situation that had to be endured. Those who used emotion-focused coping described seeking to reduce their emotional distress by using strategies aimed at changing their response to their powerless position. A range of strategies were reported including meditation techniques, acceptance, positive reinterpretation of their situation, and finding a positive focus.

Discussion Participants told a story of dangerous mental patients subjected to an institutional culture that emphasized control, bureaucratic systems, professional decision-making, and psychiatric treatment. In this narrative, the protagonists were mental health professionals, particularly doctors, who made the important treatment decisions and took the lead in directing rehabilitation. The patients, in their supporting role, undertook treatments designed to address a range of problems, particularly mental illness. As compulsorily detained and treated patients, who were often unwilling recipients of “care,” their subjective experience presented as one of powerlessness, oppression, and sometimes despair. These feelings were heightened by perceived inconsistencies in their care, confusion about where they were going in their rehabilitation, and their sense that staff did not always respond to them as people.


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However, there is a second, very different story. In fact, it is really a collection of stories about the individuals who used the forensic service—their histories, the things that mattered to them, their hopes and dreams for the future, and the reasons why things went wrong for them. In this story, the professionals were considered to be in a supporting role and the service users assumed center stage. The forensic service had a strong orientation to personcentered care, including seeing those who used the service as having needs and characteristics that extended beyond their illness, helping them to collaborate in their own care, and where appropriate and possible, promoting autonomy, responsibility, and choice. Together practitioners and service users developed holistic, personalized rehabilitation plans that highlighted strengths, as well as risk and other problem areas, and a pathway to a better life. Paradoxical though it was, the detained forensic service users reported feeling as if they were active participants in their own rehabilitation and expressed hope for the future. In reality, the participants’ narratives contained elements of both stories, but they were much more aligned with the first. This is perhaps not unexpected. In many ways, what participants had to say about their rehabilitation is similar to that reported in the forensic service users’ literature, particularly their perceptions of authoritarian practices, a lack of person-centeredness, and a sometimes haphazard approach to care. Feelings of powerlessness and oppression are part of the subjective experience of being a forensic service user in secure services where people are detained and often treated against their will (Mezey et al., 2010). Furthermore, principles such as shared decision-making between service users and professionals may be difficult to implement in a forensic setting where there are a plethora of opposing considerations relating to safety and security and some people may be too mentally ill to collaborate in their own care (Livingston, Nijdam-Jones, & Brink, 2012). More generally, there are real challenges in conceptualizing and implementing a recovery-oriented approach, encompassing principles such as autonomy, hope, and self-acceptance, in a forensic mental health context where service users may feel coerced into treatment (Mezey & Eastman, 2009; Mezey et al., 2010) although there is accumulating evidence that it is possible (Corlett & Miles, 2010; Drennan & Alred, 2012; Gudjonsson, Webster, & Green, 2010). Despite the serious challenges, there is reason to believe that there are benefits to prioritizing approaches that promote principles such as collaboration, power sharing, inclusion, self-determination, and a focus on strengths in a secure forensic mental health context. Published literature on person-centered care, treatment engagement, and recovery-oriented approaches has


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started to show that involving service users in care processes results in better outcomes (Resnick & Rosenheck, 2008; Sidani, 2008; Warner, 2010). In keeping with the authors’ epistemological position, it is assumed that participants’ experiences of rehabilitation were shaped by the restrictive setting of the forensic mental health hospital. However, other contextual factors, such as the paradigms and philosophies in use, are also likely to have influenced their experience of forensic services. Although it should be borne in mind that the data reflect participants’ perceptions and are not necessarily an accurate reflection of service provision or practice, their depictions of forensic services conformed closely to a “traditional” approach to forensic mental health care. This may not be surprising. Forensic services have primarily been professionally driven and organized according to the principles of a biomedical model that emphasizes impairment, doctor-led decision-making, and biological reductionism (Borrell-Carrio, Suchman, & Epstein, 2004; Livingston et al., 2012). It has been suggested that their geographical and institutional separation from general mental health services in New Zealand and much of the Western world has “too often left important parts of the forensic services marooned in the past” (Mullen, 2000, p. 309). How then can we understand participants’ representations of a biologically-oriented oriented psychiatric approach to forensic rehabilitation and make sense of the other findings of this study? One possible explanation relates to the apparent lack of a shared, overarching rehabilitation framework to guide all aspects of service delivery. Such a framework would include a set of guiding principles to govern how practitioners think about the people who use forensic services and the way they go about their work. In addition, it would assist practitioners to balance risk and treatment considerations and integrate a range of perspectives, including service users’ views, into a cohesive understanding of the person and his or her rehabilitation needs. In the absence of a strong, service-wide rehabilitation framework, a biomedical model embedded in the institutional culture and inherited from the psychiatric institution previously on site apparently prevailed. Participants’ general perceptions of service delivery, their self-evaluations that emphasized mental illness, and their beliefs about being viewed by some staff in terms of their diagnoses, symptoms, and medication may reflect the ascendancy of the medical model within the service. However, their accounts suggested that an eclectic mix of newer interventions (e.g., dialectic behavior therapy, cultural models) and some different paradigms (e.g., risk management models, strength-based approaches) were also in use. It is possible that participants’ confusion about their rehabilitation pathways and their perceptions of inconsistent and uncoordinated care reflect the absence of a shared rehabilitation framework to tie the different elements


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of assessment and treatment together. However, the possibility that participants’ perceptions do not accurately represent the paradigms and models underpinning rehabilitation cannot be discounted. The findings of this study must be considered with some limitations in mind. First, thematic analysis is not designed to facilitate generalization of findings but rather to pick out core meanings evident within a specific sample (Braun & Clarke, 2006). Furthermore, the relatively small sample size and the specific environmental context within which the study was undertaken suggest that it is prudent to be cautious when generalizing the findings to other settings. Indeed, the recent literature on the application of recovery approaches in forensic mental health settings (Birch, 2012; Brookes, 2012; Corlett & Miles, 2010; Miles, 2012; Smith & Garcia, 2012) and a small but growing number of studies canvassing forensic service users’ views about various aspects of their care (Bouman, de Ruiter, & Schene, 2008; Bressington et al., 2011; Carlin et al., 2005; McQueen &Turner, 2012; Mezey et al., 2010) are suggestive of efforts to foster a degree of self-determination and give voice to this population. A second limitation concerns the representativeness of the sample. Although 74% of participants who met study criteria agreed to participate in the study, the views of participants may not be entirely representative of the entire population who met the study criteria. There was inevitably a degree of selectivity in the recruitment of service users to the study as those who were very unwell or who had been detained for less than 6 months were excluded. Furthermore, the very small number of women in the sample prevented consideration of the influence of gender on perceptions of rehabilitation.

Conclusion This qualitative research explored perspectives on rehabilitation within and beyond therapeutic programs. A total of 20 people detained in medium secure and open units shared their views in individual, semi-structured interviews. The findings indicated that, from the perspective of forensic service users, the rehabilitation context was characterized by an overall lack of person-centeredness, therapeutic relationships that were of variable quality, a lack of clarity about rehabilitation pathways, and some degree of inconsistency of care. Participants’ self-evaluations were consistent with a biologically oriented psychiatric paradigm within the service. Their reported loss of agency, which they coped with in a range of ways, may reflect the forensic hospital’s emphasis on security, containment, and supervision as well as their status as compulsorily detained patients.


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The results of this exploratory study are necessarily tentative but suggest a number of concerns about rehabilitation and forensic care for at least one group of service users being treated in a forensic mental health service. Whether forensic mental health services are generally characterized by an absence of an overarching, comprehensive rehabilitation framework is unclear at this point. These are important clinical and practice issues that future research will hopefully address. Acknowledgment The authors would like to thank the participants and the staff on the wards encompassed within this research for their contribution to this study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research and/ or authorship of this article: A small amount of financial support for the research was received from the forensic service.

Notes 1. This reflects the overrepresentation of Maori in New Zealand forensic populations, including forensic inpatient populations (Ministry of Health, 2007). An examination of the cultural and racial implications of the research is required but is beyond the scope of this preliminary study that focused on general experiences of rehabilitation. 2. “Therapeutic relationships” refers to participants’ relationships with all staff involved in their care and not just those with treatment responsibility.

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Author Biographies Mary Barnao, MA, is a doctoral student at Deakin University, Australia. She currently works at a forensic service in New Zealand and has published a number of articles on aspects of forensic rehabilitation. Tony Ward, PhD, is a professor of clinical psychology at Victoria University of Wellington, New Zealand. He has over 340 academic publications and his research interests include offender rehabilitation, forensic and correctional ethics, and cognition in sex offenders. Sharon Casey, PhD, is a Senior Research Fellow in the Clinical Forensic Research Group,Centre for Mental Health and Wellbeing, Deakin University, Australia. Her research interests include substance abuse treatment, offender program evaluation, juvenile offending, scale development and validation, and psychology and the law.


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