Silent But Not Forgotten – Rare Insight into Forensic Inpatients’ Perspectives on Their Own Violence Risk Factors

Sara K. Levin; Department of Forensic Psychiatry, Linkoping University, Vadstena, Sweden; Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden

Per Nilsen; Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden

Preben Bendtsen; Department of Medical Specialist and Department of Medicine and Health Sciences, Linkoping University, Motala, Sweden

Per Bulow; Department of Forensic Psychiatry, Linkoping University, Vadstena, Sweden; Department of Behavioural Science and Social Work, School of Health Sciences, Jonkoping University, Jonkoping, Sweden; Department of Psychiatry, Ryhov County Hospital, Jonkoping, Sweden

This study investigated forensic patients’ perceptions of relevant factors for violence risk, to facilitate an understanding of potential reasons for violence and the effect of risk management interventions. Semi-structured interviews with 13 forensic patients were analyzed with qualitative content analysis using an inductive approach. The sample of participants could identify an array of potentially relevant factors for their use of violence related to themselves, the external context, social and relational aspects, as well as situational factors. Most also actively strived to manage such risk. Considering patients’ perceptions could potentially add relevant perspectives and improve clinical and structured risk assessments.

Violence; risk factors; protective factors; patient perceptions; risk assessment

“Assessment of patients’ future risk of using violence and other adverse behaviors is an integral part of forensic and inpatient psychiatric care…The importance of encouraging and providing opportunities for patients to actively participate in their own care, including risk assessment and management, is emphasized in the legislation regarding patients’ rights in psychiatric health care and clinical guidelines for mental healthcare in several countries…Including patients’ perspectives and experiences and involving them could potentially improve forensic care, risk assessment, and management interventions to reduce occurrences of violence…However, forensic and non-forensic psychiatric inpatients are seldom invited to participate in identifying or assessing their own risk and protective factors in the risk assessment…or in risk management…There is a paucity of research on the perspectives of forensic and psychiatric inpatient populations on risk- and protective factors for future violence…This study was designed to address important knowledge gaps concerning forensic patients’ perspectives of violence. The aim was to investigate forensic patients’ own perceptions about what influenced their use of violence to identify factors that can increase and reduce this risk. Such investigation can facilitate an improved understanding of potential risk- and protective factors for violence and effective risk management interventions…” (p. 383-384).

“…Individual semi-structured interviews with open-ended questions…were conducted with patients sentenced to forensic psychiatric care…Study participants were recruited from a regional forensic psychiatric clinic…Participants mentioned the relevance of several contextual risk-increasing factors for violence, also supported by previous research of patient perceptions…mentioned by forensic professionals…and included in commonly used SRAIs [structured risk assessment instruments] in forensic psychiatric settings…Findings, however, suggest there might be a difference in how contextual risk factors are discussed. In structured risk assessments for example, the individual’s lack of interest or participation in education or work are mentioned, while patients in this study tend[ed] to focus on the lack of options and ability for them to find work…Some participants describe the act of violence as a deliberate way to receive help to manage their mental illness and to leave a destructive life when previous attempts to get help had failed. These potential incentives for violence are not commonly included in clinical assessments or SRAIs, but could potentially correspond to the concept of motivators incorporated in the SPJ [structured professional judgment] assessment protocol…” (p.384-393).

“Participants expressed that being ignored and treated badly by care providers were risk factors for violence, which correspond with previous studies of forensic patient perceptions…Participants mentioned a variation of internal, individual risk-increasing factors, also found in previous research…such as mental health problems and addiction and misuse of substances…lack of insight…emotional instability…a diminished cognitive ability…problems with insufficient behavioral control…and coping strategies…Moreover, participants described individual risk factors not commonly found in previous research…such as having violent ideations, attitudes and values that legitimized and justified violence, and a sense of self-alienation and negative self-image” (p. 393).

“Participants mentioned identified various risk-reducing factors, most of which were consistent with previous research on patients’ perceptions and factors listed in commonly used, structured professional risk assessment instruments…Findings support that forensic patients can themselves be active participants in gathering an understanding about mitigating factors for violence and continuously managing their risk of engaging in violence using a variety of coping strategies…Participants mentioned several risk-reducing factors, such as realizing you need help and having a readiness for change and taking responsibility, having insight and an empathic ability, access to a prosocial network and relationships, and having sufficient coping strategies…Improving their insight and understanding of triggers and warning signs for violence was perceived as risk-reducing and the importance of staff supporting patients to understand and manage such triggers is stressed in clinical guidelines…Participants also emphasized the relevance of being able to regulate their own behavior and emotions to reduce their own aggressive feelings, impulses, and behavior to reduce their risk of turning to violence…Coming to a complete halt with engaging in violence by being incarcerated and spending enough (but not too much) time in confinement was a protective factor mentioned by participants…” (p. 393-394).

“Having access to and support from staff decreased the risk of violence, according to participants, which is also emphasized by the staff…However, participants also mentioned the importance of having a good relationship with care providers and being well treated by them…Some participants also stressed the importance of having external monitoring and control to reduce their risk of turning to violence…Being able to find and be themselves again and having a sense of self connection and self-efficacy were mentioned by participants as risk-reducing…” (p. 394).

“…Experienc[ing] negative consequences of violence, as opposed to only imagining them, seemed to be a separate factor according to the patients’ account in this study. Talking about the side effects of violence that patients themselves had experienced could be helpful to improve forensic patients’ insight and motivation to refrain from violence…The similarities and differences in perceptions of violence risk and grounds for assessment between forensic psychiatric patients, clinical staff, and risk assessors relying on structured risk assessment instruments have several implications. It can influence the daily clinical risk assessments and the management strategies that staff employ…the structured risk assessments provided by the risk assessor to care teams to guide care and risk management plans…and to courts. It also ha[s] implications for forensic patients’ participation to potentially improve such assessments…and feasibility of successfully completed care- and risk management plans…and to courts…” (p. 394).

“The relevance and implication of risk-increasing or risk-reducing factor[s] for violence can be very different for specific individuals and groups of people, as well as how risk management and treatment interventions to mitigate violence are employed in cooperation with the patient. Participants in this study also mentioned risk factors potentially influencing their violence, not mentioned in previous studies on forensic patients’’ perceptions, indicating that there are differences within these populations that need to be considered and further investigated. This study supports the notion that forensic patients are capable of communicating their perceptions of mediating factors for violence…There need to be a truly reciprocal communication to fully elaborate and make use of patients’ perspective and all the nuances and to facilitate a genuine shared knowledge and understanding between forensic patients, clinicians, and risk assessors using structured risk assessment instruments. The prerequisites of patients’ participation in their own risk assessments and ways of incorporating their perspectives in such assessments and risk management plans need further investigation” (p. 394-395).

“Previous research on forensic and non-forensic psychiatric inpatients’ perception of risk and protective factors and efficient risk management strategies for violence show that they view aggression as being caused by a range of factors, including interpersonal factors, such as the patient’s mental illness; external environmental factors, such as a restrictive environment; and situational, interactional, and relational factors, such as communication between staff and patients and staff listening to patients…Forensic and non-forensic psychiatric inpatients are often concerned about risk factors for violence such as detrimental effects of medication, risk o of violence posed by other patients, isolation and loss of family contact, and inactivity…A few studies have also investigated what patients do to prevent themselves from resorting to violence. These studies found that patients use a variety of strategies to manage their mental illness and risk situations…” (p. 384).

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