We Are (Still) Family: A Thematic Analysis of the Positive Impact of Familial Support in Forensic Populations

Martha Gillespie; Clinical and Health Psychology Department, University of Edinburgh, Edinburgh, UK; Clinical Psychology, The State Hospital, Carstairs, Lanark, UK

Ethel Quayle; Clinical and Health Psychology Department, University of Edinburgh, Edinburgh, UK

Joe Judge; Clinical Psychology, The State Hospital, Carstairs, Lanark, UK

Research has identified positive relationships between familial support and outcomes for forensic mental health patients. Such support has been linked to reduced recidivism, improved mental health and increased prosocial behavior. Whilst some studies have explored families’ experiences of providing such support, there is a paucity of research exploring patients’ narratives. Using Interpretative Phenomenological Analysis, the current study interviewed patients at a high secure forensic hospital and asked questions about their experiences of familial support. Results indicated four superordinate themes; Connection, Growth, Power, and Ambivalence. These results are discussed in relation to existing findings and clinical implications. Areas for future research are suggested.

Family; support; patients; forensic; qualitative

“Familial relationships and associated support have been shown to have a significant and lasting effect on individuals’ wellbeing within the general population…Therefore, one may be inclined to hypothesize that maintained familial relationships within custodial forensic populations could hold an even stronger importance, due to the often-distressing nature of their imprisonment…and separation from preexisting support networks…This study set out to explore the ways that patients within a high secure forensic hospital experience familial support. By drawing on qualitative methodology, it focused on the perceived importance of familial support, how familial support changes in a high secure hospital, the values that are placed on familial support, and the experience of receiving familial support within a sample of patients who have maintained such support” (p. 333-336).

“Many participants described ways in which family visits provided opportunities for them to connect with their true selves. Due to participants’ lack of immediate connection with people, places, and the social context within which they had oriented themselves prior to hospital admission, they were stripped of the social anchor points which had previously allowed them to maintain their ‘true’ sense of self. In a recent systematic review and narrative synthesis of qualitive studies which explored what recovery meant to forensic mental health patients (Clark et al., 2016), two of the key themes identified were Connectedness and A sense of self. These themes clearly map onto data identified in the current study…whilst the present study does not look explicitly at the role of familial support in recovery, the two became inextricably linked, given that the opportunity to connect with a more hopeful narrative is established through a sense of connection” (p.343).

“Another theme identified from the data gathered in the study, Growth, spoke to the way the family visits offered a space from which growth could happen in various ways. For some, visits provided an opportunity to consider what life could be like once back in the community. When this future focus was present, participants’ ideas of what the future would be like was unanimously positive which made them feel ‘cheered up…’ As research findings highlight that positive subjective wellbeing can reduce both short- and long-term recidivism in forensic populations…it is worth considering that thinking about the future in a positive way can cultivate a sense of security in these individuals, which can in turn promote positive outcomes in a reduction in recidivism. However, thinking about the future has also been described as anxiety provoking for forensic patients due to imagined challenges of the transition into the community…” (p. 343).

“Participants described the way that Power operated in the visits in many ways. Of prominence was the frequency of excerpts highlighting that many visits between patient and family member were observed by staff. Some participants found these observational processes an imposition and suggested this inhibited the natural flow of their conversations with family members…Staff observation could therefore inhibit therapeutic ‘opening up’ that was described across the dataset…Another way in which power operated during visits was that visitors were at liberty to choose when, why, and if they chose to visit, whilst patients became passive recipients to such decisions…The loss of power and control can lead to psychological distress such as anger, frustration, hopelessness or depression…and a lack of interest in the future…” (p. 344).

“Results also described the dual nature of receiving familial support: it was often welcomed, meaningful and celebrated; yet could be emotional, difficult and, at times, embarrassing, in that the family presence served to remind them of the wider impact of their offending…In order to accept social consequences of one’s offense history, offenders may require a social context within which to do this. Therefore, social visits from family or peers could be necessary to support this process of acceptance and change…” (p. 344).

“Many participants described being unsure of what to talk about and a lack of conversational flow with family members during visits, sometimes due to a small repertoire of stories to share given the reported lack of variety in their lives. This caused nervousness about visits, which could in turn affect the visits themselves. In light of this, coupled with the knowledge that forensic mental health patients often have relational difficulties…one might argue it is staff members’ duties to consider ways to foster and bolster communication during family visits. If, as professionals, staff are aware of the relational challenges inherent in patients’ presentations, as well as the potential benefit of maintaining familial relationships, clinicians could utilize problem solving techniques and adopt a holistic approach to patient care in order to support these processes in order to encourage positive outcomes” (p. 344).

“When considering the results of the current study and those of Clarke et al., (2016), one could argue that the maintenance of a sense of connectedness in forensic populations is so important to some that it could contribute to successful recovery and rehabilitation processes. With this knowledge, forensic settings could consider ways of sensitively encouraging opportunities for forensic patients to maintain relationships which could foster a sense of connectedness to promote the potential for positive recovery outcomes…” (p. 345).

:…Given the benefit of learning [honest and vulnerability] for future relationships in the community, forensic settings could consider more overtly the value of directly supporting patients to access and maintain family visits, particularly given the incidence of relational difficulties in this population as a result of unhelpful or traumatic childhood relationships…By learning successful relational skills, this could promote effective transition through services and rehabilitation in the community. Furthermore, given the importance of therapeutic relationships in enabling successful treatment processes for forensic patients…providing relational support for patients who may struggle to maintain positive relationships could be effective in supporting treatment in a holistic way. Staff should consider the ways in which they can promote a sense of privacy during familial interactions…” (p. 346).

“A balance in the recognition of both positive and negative potential outcomes of familial support should be acknowledged by staff and policy makers when considering and supporting family visits. Clinical staff involved in the facilitation of visits should consider carefully the individual’s responses to family visits. While standard practice does not tend to encourage clinical staff to formally debrief with patients following family visits, allocating time to explore individuals’ responses, views and beliefs about family visits may be a worth additional piece of assessment and formulation material…Future research should also explore beyond the nuclear boundaries of family when considering the role of familial support in forensic patient settings. Given the potential for a broader conceptualization of such support by widening the lens of what family means, a more nuanced account of this phenomenon could be accessed” (p. 346).

“When considering attachment in forensic settings, admission processes enact a separation or removal from familiar settings within which patients reside prior to admission. Being moved into a new setting which is locked and may be characterized by an imbalance of power and control could act as a frank reminder of historical attachment disruptions…With this in mind, in addition to lack of perceived social support and autonomy in such settings…one could argue that the locations within which detained forensic patients or prisoners live do little to foster a secure base that offers a remedy to attachment disruptions. Furthermore, individuals from forensic populations are drawn disproportionately from marginalized groups in society…Since there is a strong prevalence of attachment disruptions within these groups…more could be done to work with this knowledge, perhaps by considering the change in relationships during detention…the impact offenses may have upon relationships…and the impact of maintained relationships for the individual during detention…” (p. 334).

“Social exclusion has been connected to difficulties with antisocial behavior and poor self-regulation…This is important to bear in mind when considering the experience of patients in an inpatient forensic hospital, separated physically from community and familial ties…In this sense, not only may social exclusion be an undesirable outcome related to admission to a forensic hospital, but negative effects such as antisocial behavior and poor self-regulatory skills may also be implicit…This also mimics our understanding of the effects of childhood trauma, as trauma can impair the development of emotion regulation processes which may impact intra and interpersonal behavior in a multitude of ways…” (p. 334).

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