Risk and the regulation of communication in relation to service users' and providers' experiences of forensic mental health care

This thesis presents a qualitative study of service users’ and providers’ experiences of one UK inner city medium secure forensic mental health service. The study focused on the processes through which service users and providers attempted to manage their risk status. Aims The study had three main aims: 1. To develop a greater understanding of the complex formal and informal risk assessment and management processes operating in medium secure forensic mental health services. 2. To investigate the processes through which providers and users of medium secure services attempt to manage risk by balancing safety with the promotion of service user autonomy. 3. To generate recommendations derived from the study findings for the development of forensic mental health services. Methodology and methods A qualitative grounded theory methodology was used to explore forensic mental health care from the perspectives of service users and providers. Data were collected through lightly structured interviews and participant observation. Participant observation occurred over a period of eighteen month. Activities that took place within the service were observed and spontaneous informal conversations between the researcher and participants recorded. A theoretical sampling approach was adopted. Design, data collection and analysis were done in cycles so that the direction of inquiry could be grounded in participants’ concerns. Eventually, data collection and analysis were organised around the core category of the regulation of communication. Findings The regulation of communication was analysed in relation to three other important categories: the management of own risk status; the dynamics of self-forming groups; and external role expectations. It is hypothesized that the regulation of communication provided a means of attempting to meet competing role expectations and thus manage risk status. Conclusions The study provides an insight into how service users and providers situated within a complex and conflicted system may attempt to manage their risk status through regulating their communication. This strategy enables service users and providers to attempt to achieve the highly problematic mission of the forensic mental health service; to provide mental health care and public protection. However, organisational learning and risk management may be hampered by the regulation of communication as information regarding clinical and organisational risks may be silenced within official organisational systems. Furthermore underlying problems may remain unresolved for users and providers who feel unable to express dissent