What Happens after Discharge from a Forensic Psychiatric Hospital?: An Analysis of Causally Complex Patterns of Recovery among People Found Non-criminally Responsible on Account of Mental Disorder | 2023 Vol. 22, No. 2, 136-146
B. Heylen; Direction de la recherche et de l’enseignment universitaire, institute Philippe-Pinel de Montreal, Montreal, Quebec, Canada
M. Caulet; Direction de la recherche et de l’enseignment universitaire, institute Philippe-Pinel de Montreal, Montreal, Quebec, Canada
M. C. Seto; Institute for Mental Health Research, The Royal, Ottawa, Ontario, Canada
T. Nicholls; Department of Psychiatry, University of British Colombia, Vancouver, British Columbia, Canada
A. G. Crocker; Direction de la recherche et de l’enseignment universitaire, institute Philippe-Pinel de Montreal, Montreal, Quebec, Canada
In this article, we explore which configurations of risk and protective factors explain recovery in a sample of 60 forensic psychiatric patients 6 months after they have been discharged from a psychiatric institution. In line with the recovery-oriented paradigm that emerged in psychiatry, we focus on the role dynamic risk factors and dynamic protective factors play in recovery. Using fuzzy set qualitative comparative analysis, we explore which configurations of conditions explain recovery in conjunction with each other. This entails that the configurations of conditions are codependent sets of conditions, in the sense that the conditions in the configuration explain recovery only in the presence of the other conditions in the con- figuration, with important implications for research and practice. Our results suggest that the absence of dynamic risk factors is a necessary condition for recovery, and that both the absence of dynamic risk factors and the presence of dynamic protective factors play a pivotal role in recovery, often in combination with other factors, such as absence of symptoms, absence of historical risk factors, and absence of alcohol dependence. We conclude by stressing the important role dynamic risk and protective factors play in recovery, and under- line their co-dependence on other factors.
Qualitative comparative analysis; recovery; risk factors; protective factors; dynamic factors
Summary of the Research
“People found non-criminally responsible on account of mental disorder (NCRMD) often have long histories of contact with police or the judiciary…Thus, an in-depth understanding of what recovery – an inherently multifaceted concept – is and which factors promote it is of primordial importance in the creation of better interventions and community integration programs, which in turn may contribute to breaking the cycle of hospitalization and potential justice involvement…In the current study, we adopt Corrigan’s psychological approach to recovery, an approach in line with patients’ views of recovery as a process encompassing self-esteem, self-orientation, empowerment, quality of life, and support…We are primarily interested in exploring the role dynamic risk and protective factors play in recovery as these have been relatively under-studied to date, especially dynamic protective factors. We will include a number of well-studied static factors in order to see how these dynamic risk and protective factors interact with static factors. Instead of formulating hypotheses our goal is to explore the complex interactions that may exist among these factors using a novel method in the field of psychiatry…” (p. 136-137).
“In the current study, we will focus specifically on out-patients…The focus on a sub-population of the general forensic population (i.e., individuals found NCRMD) in combination with a focus on both static and dynamic risk and protective factors is, to our knowledge, novel in the field of forensic psychiatry…Our results suggest…the absence of dynamic risk factors was a necessary condition for recovery to occur. Notwithstanding the fact that dynamic protective factors are not a necessary condition for recovery, our results revealed that…they do play an important role…Second, we wanted to see if the dynamic risk and protective factors in the study were codependent on other factors in the study. Our results indicate that this, indeed, is the case: in all of the configurations of the conditions that produced recovery, multiple factors are present, indicating higher-order interactions between these factors…” (p. 136-144).
“Third, we investigated which of these configurations of conditions explain recovery more commonly, and which are the more rare ones. Based on our analysis, the most common configuration of conditions was the conjunction between the absence of symptoms, the presence of dynamic protective factors, and the absence of dynamic risk factors…Finally, we wanted to see if the different configurations of conditions uniquely explain recovery or if there is overlap between them. Our results suggest that there is a considerable degree of overlap between the conditions…Thus…this particular configuration of conditions may equally well be explained by the other configurations of conditions present in the [analyses]…” (p. 144).
Translating Research into Practice
“…dynamic risk and protective factors ought to be at the center stage in both theorizing on recovery and in interventions aimed at achieving recovery…solely focusing on dynamic risk and protective factors in order to achieve recovery will not suffice; attention should be given to other conditions in the configuration that, in conjunction with dynamic risk or protective factors, produce recovery…From a theoretical point of view, this particular result [i.e., absence of symptoms, presence of dynamic protective factors, and the absence of dynamic risk factors comprised the condition that was most strongly associated with recovery] implies that theorizing on recovery ought to center around dynamic risk and protective factors, dynamic risk factors in particular given that they are also a necessary condition for recovery…Future research might consider using a larger, mixed sample of patients considered recovered and patients considered not [to] be recovered in order to increase the robustness and generalizability of the results. In addition, such an approach might shed more light on which factors produce different levels of recovery…” (p. 144).
Other Interesting Tidbits for Researchers and Clinicians
“Static or dynamic protective factors can be understood as factors that promote recovery and community reintegration, and may also provide buffers against risk factors. Dynamic protective factors can relate to a wide variety of domains and levels such as characteristics of the individual, structures of support available in the individual’s environment, and factors related to the individual’s immediate and wider community or social environment…The scarce studies available on the subject indicate a lower risk of aggression and violence in short-term follow-up research if a person’s protective factors exceed her or his risk factors…” (p. 137).
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