Petra Schaftenaar, member of the research network Critical Ethics of Care, presents a summary of the results of her PhD-thesis Aiming at contact. Relational caring and the everyday interaction as effective principles in clinical forensic care (2018) in the following article.
The subject of this research, which I conducted between 2014 and 2017, is the value and meaning of relational care in forensic psychiatry. The problem addressed in this study is that the usual way of treatment of forensic psychiatric patients with short-term judicial measures who suffer from mental disorders does not sufficiently contribute to the reduction of criminal recidivism. The aims of this study are 1) to contribute to the knowledge on relational care in forensic psychiatric practice. The second aim is 2a) to promote good care by examining the value and meaning of relational care in a forensic psychiatric hospital and 2b) to develop knowledge on the meaning of relational care against the background of the biographies of the lives of patients (i.e. care-receivers) and against the background of the work of professional staff (i.e. caregivers). An additional aim is 3) to give ‘voice’ to patients and professional staff in forensic psychiatry. The final aim 4) is to examine if relational care can contribute to the reduction of criminal recidivism.
2. Theoretical framework
The main goal of forensic psychiatric care is the reduction of criminal recidivism. Regular approaches for forensic patients with short-term judicial measures do not stop the revolving door: after committing a crime detention follows, subsequently an admission to mental health care, and when a new crime is committed, back into de legal system. Fragmentation of the lives of the patients (lack of social support, problems in school careers, no job or meaningful activities, multiple treatments and involvement of the healthcare system) is easily reproduced and continued over long periods of time. The mental healthcare that patients receive is unconnected: after a forensic treatment patients are referred to a new (mental healthcare) facility where they have to start all over again, leaving everything behind.
The theory of presence provides a concept of good care and successful practices of care. Not only illness, disability, individual care needs and impairment are guiding principles in treatment or support, but even more the pain, suffering, loneliness and banishment patients experience, as well as their yearning for acceptance, engagement and participation. In order to connect with these yearnings in accordance with the theory of presence, professional caregivers have to provide care based on their relationship with the patient. It is in this relationship that the patient will gradually show his fear, pain and yearning.
Relational care differs from the ‘therapeutic relationship’ or ‘working alliance’ in that these therapeutic factors constitute strategically used instruments to reach a certain goal (becoming better, developing skills, using medication). In the theory of presence, the relational component has a meaning on its own, independent from any instrumental purposes. Relational care during treatment contributes to trust in patients. They become able to show who they are (and accept that), and receive support to reorganize their lives.
The theory of presence brings in the opportunity to stay in contact after the treatment has ended. This was realized at the facility where the research took place. The relationship between patient and professional caregiver may be useful for treatment, but in particular has a value on its own, and gives meaning to both patients and professional staff. By keeping in voluntary contact after treatment, not only continuity of care is guaranteed (patients may be referred to other health care facilities), but also continuity of meaningful and supportive relationships. In this study I examined whether and if yes, to which extent relational care and after care was implemented in practice.
3.1 Practices of relational care in forensic mental health
The daily practice of relational care on the wards is examined by means of an ethnographic study, with data collection by participant observation and a focus group interview at two wards of the Forensic Psychiatric Clinic (FPK), where care-receivers with short-term judicial measures were admitted. The central question was how these forensic practices of relational care appear. In order to study the value and meaning of relational care in forensic psychiatry care, insight had to be gained in daily practices.
Analysis shows that relational care was realized at the wards, and that it proved to be a valuable addition to forensic psychiatry. By providing relational care, under certain circumstances, rehabilitation occurs. To support rehabilitation of patients, professional caregivers try to ‘manage’ the unusual life of patients at the ward and the resulting stress. In order to do so, this study shows that professional caregivers must be able to develop some core qualities, such as being able to create every day normal life, and to build natural mutual relationships with patients in order to diminish the burden of involuntary residential care.
In addition, professional caregivers should demonstrate a high level of acceptance, giving unconditional support, and they should refrain from continuously correcting patients. Professionals also have to narrow down the power balance by being approachable, communicative and close to patients. Caregivers who are able to work in a relational way combine casualness with closeness and limit setting. The final insight is that relational care requires reflexive professionals, who fully understand the meaning of an involuntary residential placement for their patients, and how this may affect them.
3.2 The experiences of (ex) patients
A narrative study was conducted to examine the perspective of (ex) patients. The central question pertains to the meaning of relational care, and voluntary contact after treatment. The narratives of participants show that patients are disappointed and hurt by what life has brought them. Their reflections on the admission in the FPK, despite mixed experiences, were positive. Patients really count, they feel ‘seen’. Their desires matter to caregivers. Their experiences of a normal life during admission, the homely and personal atmosphere and the closeness and recognition of the professionals added to this. By keeping in contact after treatment, patients experience that what they go through is worth the effort (of visiting and listening). The contact makes them feel ‘seen’ and it cheers up. It brings trust: ‘they believe in me’.
3.3 The value and meaning from professional perspective
The research question in this study is what meaning professional caregivers in forensic psychiatry give to post treatment contact as a consequence of relational care. To answer this question, a mixed methods design with three types of data collection (questionnaires, case file analysis and a focus group interview) was conducted. One of the results of this study is that maintaining contact after treatment is not incidental. Since the introduction of this practice, 232 patients were discharged, 72,4% of them had contact after treatment. Relational care and maintaining contact after treatment are valuable for both workers and the organization.
The benefits are threefold. 1) At the professional level, it contributes to motivation (it is advantageous and it makes professionals proud) and it contributes to the development of the professionals and the team in terms of collaboration and reflection. 2) Keeping in contact after treatment contributes to the quality of care by knowledge-transfer. Experiences of workers in contact with ex-patients and reflections about their clinical treatment are transferred to actual situations in clinical care. Professionals are, by providing aftercare, able to better cope with difficult situations. 3) Relational care and maintaining contact after treatment promotes self-organization, collaboration, reflection and creativity, and thereby contributes to the development of autonomous and responsible professionals.
3.4 Criminal recidivism
The final research question is whether the combination of relational care and maintaining contact after treatment is effective in the reduction of criminal recidivism (prevalence, time to re arrest, and severity) by ex-patients treated under the article 37 act of the Dutch penal law (involuntary psychiatric hospital admission, with a maximum of one year) compared to ex-patients treated under the article 37 act of the Dutch penal law, who did not receive relational care and contact after treatment. In an ex post facto experimental design, three groups were distinguished and studied.
The first group, ‘contact after treatment’ (n = 45), received relational care, and was offered voluntary contact after treatment. This group consists of all patients with an article 37 act, discharged between September 1, 2012 and March 1, 2015. The historical group (second group, n = 43) received treatment in the same FPK, but they were discharged between 2007 and 2010, when relational care and contact after treatment had not yet been implemented as a policy. The third group, ‘3 FPK’ (n = 23), consists of all ex-patients treated under the article 37 act, discharged from the three other Forensic Psychiatric Clinics in the Netherlands in the same period as the ‘contact after treatment’ group. In these facilities, relational care and maintaining contact after treatment is not a part of the treatment.
Criminal recidivism two years after discharge within the group that received relational care and contact after treatment was 15,6%. In the two similar groups that did not receive relational care and contact after treatment, 46,5% (Inforsa TAU) and 47,8% (Multicenter TAU) committed a new crime within two years after discharge. The odds-ratio in the first group (.245) is four times lower than in the other groups. These findings suggest that relational care and keeping contact after treatment reduce recidivism and can thus be an effective intervention. This form of relational care and informal aftercare may bridge the gap patients experience when they are transferred between facilities in the mental healthcare system. The positive findings of this study are in line with results of research on the effects of aftercare after detention.
The results of this study emphasize ‘the strengths of normalizing ‘day-to-day living practices’ in residential forensic care. Professionals apply a range of educational aspects, which strengthen the rehabilitative opportunities normal everyday life brings. Doing ordinary little things (together) contributes to meaningful mutual relationships between patients and professional caregivers, and positively affects the atmosphere on the ward (and in the institution), including perceptions of safety.
In these studied practices of relational care, we observed that professionals are persistent. They do not give up easily on patients. Relational care is confronting in its own way for both patients and professionals caregivers. It is often said that relational care is ‘doing nothing’ in that joining patients is just ‘doing what they want’.
However, that is not what relational care is. Connecting and attuning to patients is not ‘agreeing with what they want’, or avoidance of disagreement and conflict. Relational care does require contact maintenance, even, or especially when it is hard, when patients are ‘unmotivated’, or ‘serving their time’ or when they suffer from severe mental disorders, or are extremely vulnerable and show challenging behavior. To support professional caregivers adequately, the professional first has to be with the other in a dedicated and attentive manner.
This study has provided empirical evidence that supports the use of relational care in forensic psychiatry by conducting a mixed methods study with experimental and qualitative research designs. This also expands the scope of the theory of presence.
The results of this study show that relational care and maintaining contact after treatment bring additional value to a ‘complex’ and ‘difficult’ area of offender rehabilitation: forensic psychiatry. The value is fourfold: for care-receivers, professionals, organization and community (in terms of reduction of criminal recidivism). These findings support efforts to develop new programs that support relational care in complex practices, and provide a rationale for further research on the relational paradigm in health care.
This paper is based on the summary of the PhD-thesis Aiming at contact. Relational caring and the everyday interaction as effective principles in clinical forensic care. (2018) by Petra Schaftenaar.
The study on criminal recidivism was also published:
Schaftenaar, P., van Outheusden, I., Stams, G.J. & Baart, A. (2018) ‘Relational caring and contact after treatment. An evaluation study on criminal recidivism’. International Journal of Law and Psychiatry 60 (2018) 45–50. https://doi.org/10.1016/j.ijlp.2018.07.011