Relational care in forensic psychiatry

Petra Schaftenaar, who participates in Critical Ethics of Care, gives insight to her PhD research on relational care in forensic psychiatric care in the Netherlands.

In forensic psychiatric care in the Netherlands we can distinguish care in conditional and unconditional (all involuntary) treatment. Unconditional treatment is the Dutch ‘tbs-system’, when a patient is sanctioned for two years, which can be extended by a special judge in case there is a high risk of recidivism in relation to insufficient treatment progress of psychopathology. The mean treatment duration in the ‘tbs’ is 8 years. The other unconditional forensic treatment is involuntary admission for the duration of one year in a psychiatric hospital under the article 37 act of the Dutch penal law (‘hospital order’). Compared to tbs, this is a short-term judicial measure. Research shows that recidivism among forensic patients with an involuntary hospital admission, a short judicial measure, in The Netherlands is high (over 36%, the recidivism after tbs-treatment is around 20%).
Characteristics of the background of patients are a history of discontinuity and many efforts by care institutions to build up a working alliance. Having multi problems (e.g. psychiatric disorder, addiction or abuse of drugs, mental disabilities, no degrees or job) is no exception.

Regular approaches

The regular (state-of-the-art) approaches for forensic patients with short term judicial measures do not stop the revolving door (after committing a crime being detained to prison, then an admission in mental health care and when a new crime is conducted, back into de legal system). The fragmentation in the lives of the patients (lack of social support, problems in school careers, no job or meaningful activities, multiple treatments an admissions in the healthcare system) is easily reproduced and continued in the health care chain. Healthcare 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.

Relational care; the theory of presence

To cope with this problems a new paradigm of relational care, with core elements of trust and sustainable connection was developed in a forensic psychiatric hospital in Amsterdam, Inforsa. This paradigm, based on the ‘theory of presence’ is not common in Dutch forensic care.
The theory of presence gives a framing of good care based on critical concepts and the study of successful practices of care. Not only illness, disability, need and impairment are guiding, but even more the pain, suffering, loneliness and banishment care-receivers experience, as well as their yearning for acceptance, engagement and participation. In order to connect with these yearnings conform the theory of presence, the care-giver has to give care based on the relation that is developed with the care-receiver. It is in this relation that the care-receiver gradually shows his fear, pain and yearning. Relational care differs from the on first sight related concept of ‘therapeutic relation’ or ‘therapeutic alliance’.
The theory of presence brings in the opportunity to stay in contact after the care formally has been ended. The constituted relation between care-giver and care-receiver is useful for the treatment, but also has a value on its own and gives meaning tot both care-giver and care-receiver. You do not want to stop that on formal reasons. By keeping in contact after treatment, not only continuity of care is guaranteed (care-receivers are referred to other facilities) but also continuity of relation. In this research we study if and to what level this becomes practice.

An educational program

At the hospital, an educational program in relational care was developed and special attention was given to the ward-climate. A non-repressive atmosphere, trust and doing things together were important aspects. Also, the workers provided voluntary contact after treatment. Every discharged patient was offered to keep in contact with the person he/she wanted (nursing staff or therapist).

The aims of the study

The aims of the study are:
1) to contribute to the knowledge on relational care in a forensic psychiatric practice.
(2a) to promote good care by researching the value and meaning of relational care in a forensic psychiatric hospital and
(2b) to develop knowledge in the meaning of relational care against the background of the biographies of the lives of care-receivers and against the background of the work of caregivers.
3) To give ‘voice’ to care-receivers and caregivers in forensic psychiatry.
4) To study if relational care contributes to the reduction of criminal recidivism.


To discover the potential value and meaning of this way of working, an explorative mixed-methods study was conducted, with four elements.
First of all, a participant observation was done in order to describe this way of working in a forensic setting. Secondly, ex-service users were interviewed to enlighten their experiences in (forensic) care and the value this practice added them. Thirdly, in a combination of file-study, questionnaire and focus group, workers were questioned about their experiences. These three qualitative studies are combined with a quantitative study on criminal recidivism. In an ex post facto experimental design, three natural occurred groups were distinguished and studied. The first group is ‘contact after treatment’ (n=45). This group 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 was not 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 (FPK) in the Netherlands in the same period as the group contact after treatment’. In these facilities, relational care and keeping contact after treatment is not a part of the policy.

Results of the study

The results of this study show that relational care and keeping in contact after treatment brings in value in a ‘complex’ and ‘difficult’ area: forensic psychiatry. The value is fourfold: for care-receivers, professionals, organization and community (in terms of reduction of criminal recidivism). While the study is not yet presented in The Netherlands, outcomes cannot be presented here at this moment.
The study will be published in Dutch (with a summary in English). Some chapters will be presented as papers to international journals. The study is supervised by prof. dr. A. Baart (‘founder’ theory of presence) North-West University, South Africa and prof. dr. G.J. Stams (University of Amsterdam).

Petra Schaftenaar (bachelor degree social work and master degree in business administration), the researcher, was manager at the FPK Inforsa between 2011 and 2014. In 2014 she started this research in her job of researcher and ‘care-innovator’. In the latter part she contributed to teaching in relational care and recovery oriented practices. She also conducted other research projects (Action research on patient satisfaction and several studies on reduction of seclusion). After development of the program/policy of relational care and keeping contact after treatment between 2012 and 2014, she was admitted to the Graduate School of the University of Humanistic Studies in Utrecht in 2014. This study has been conducted between 2014 and 2017. On the 12th of July 2018, 10.30, Petra Schaftenaar will defend her dissertation in the Academiegebouw, Utrecht.

About the author: Petra Schaftenaar

Petra Schaftenaar

Since 1993 Petra Schaftenaar is 'care-innovator', researcher, developer and teacher, based on years of experience in (forensic) psychiatry as carer and manager. She contributed to teaching in relational care and recovery oriented practices and conducted several research projects. She recently started working as an independent care professional in her own company Metis Zorg.

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