The barriers and facilitators influencing the effectiveness of high secure forensic care: a critical realist qualitative study

This thesis examines the barriers and facilitators influencing the effectiveness of high secure forensic care. Forensic psychiatric care is concerned with the assessment and treatment of mentally disordered offenders who are detained under various sections of the Mental Health Act. A prime function of forensic psychiatric care is the management of risk, and the protection of the public. In England, high secure forensic care is provided at Rampton, Broadmoor and Ashworth hospitals, and to be admitted to high secure care patients must be considered a grave and immediate danger to the public or themselves. This risk management places restrictions on the lives of patients however, there is a need to balance the management of risk, with promoting recovery and rehabilitation of patients with the need to maintain safety and security. The study took place at Rampton Hospital, a large high secure hospital in the East Midlands of England and employed a series of qualitative semi-structured interviews. Questions focused on patients’ experiences of care, and their views of factors which may be barriers or facilitators of their care. Interview questions were open ended, with follow up questions being posed to expand on points and to increase the richness of the data. Semi-structured interviews were chosen to give potentially vulnerable participants an opportunity to narrate their personal experiences to make their views known. This study considered participants to be experts by experience of receiving high secure forensic care, with the study highlighting their narratives of factors which they described as barriers or facilitators of their care. The study applied a novel and innovative approach by using critical realism as a philosophical position for its literature review and empirical study. This allowed broad consideration of a variety of factors which have the potential to impact on the effectiveness of high secure care Study findings indicated that factors relating to role and identity, therapeutic activity policies and procedures, and significant relationships have the potential to impact on patient care, with role and identity being the most significant. This study clearly demonstrated the importance of role and identity in the care and recovery of high secure forensic patients and recommended that identity should be routinely considered in treatment planning. The study also highlighted the difficulties in evaluating interventions in the area due to the many factors which have the potential to influence care. The study also emphasised the lack of research in this area and the difficulties associated with evaluation research particularly form a quantitative approach. It was therefore advocated that critical realism should be considered as a philosophical approach with the potential to enhance research in high secure forensic care