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Personal reflections around the United Kingdom forensic-psychiatric model: Is there a better way forward?

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education and training, research

I have recently had the opportunity to visit through an EU-sponsored Short Term Scientific Mission (STSM) a forensic-psychiatric institution in the Lake Garda region of northern Italy. This was a unique chance for me to learn about forensic-psychiatric models of care outside the United Kingdom and engage in critical thinking about what is effective and what is improvable in the current service provision. I was particularly interested in learning about the population I am investigating in my PhD, older patients and older patients with cognitive impairment/dementia, who constitute a consistent and increasing share of the total population in the forensic-psychiatric context of many European countries, including the UK and Italy.

Having experience of the tight security regime of the UK forensic-psychiatric model, I must admit that I was flabbergasted by the Italian way of managing individuals who are at high risk of harming themselves or others. In order to gain access to Rampton hospital (the high-security service where I am collecting data for my PhD) I received clearance after a full DBS checks and a one-week induction programme, which included among training in safeguarding, fire safety and de-escalating aggression, a full day self-defence course. The inductees were also provided with a personal set of keys and a panic button to be used in an emergency. We were also clearly told that any failure to comply with security rules would results in expulsion from the premises, effective immediate.

Needless to say, upon embarking on this Italian adventure, I was expecting a similar anxiety-provoking scenario. On my first day at the Italian REMS (Residential facilities for security measures) however, I was not asked to go through any security checks or body scans and even more unexpectedly, I was not threatened to be escorted out by security if I accidentally forgot to lock a door or left a key hanging from my belt. There simply were not any keys or belts! Contrary to my first time at Rampton, on this occasion my initial impression was that I was entering an actual hospital, rather than a prison.

The hospitality of the place continued to surprise me once I gained access beyond the “security perimeter” (I cannot help but reflect on the fact that even the terminology we are used to in the UK is a strong element of a “culture of fear”). Here the atmosphere was unexpectedly relaxed: The patients were free to move around unaccompanied and the personnel seemed more concerned to engage in human contact than in developing key-related OCD. A profusion of amical gestures (which include patting, hugging, caressing) between patients and staff was widespread (so stereotypically Italian, I know…) and cherry on top of the cake, the patients had unlimited and unrestricted access to all the facilities, including a user-led café’, a gym, a cultural centre and a football field. Finally, social events were organised in which male and female patients could mingle and have a social life. On my first day, I was also explained that in the REMS the staff is made up of healthcare professionals only and that no guards or police enforcement is present. The nearest police station is located in a village “within easy reach” (and I am being sarcastic here, given the 15-minute drive). I was reassured however, that serious incidents are extremely rare occurrences, which I did not find it hard to believe, as even at a very superficial glance the patients mostly looked unthreatening to me (they were playing bowls on that morning).

Overall, had it not been for the poor infrastructure of the REMS (I was told the place was about to the renovated), which did not surprise me given the epidemic lack of adequate public funding in the Italian NHS, this all looked as recovery heaven for patients. Suspicious (and curious) by nature as any researcher, I immediately wondered what the flip side of the coin would be. I assumed that the highest standards of security (and the large amount of public investment that this entails) in the UK forensic-psychiatric system must be somehow justified in terms of reducing the number of incidents, given that research has proven how coercive measures negatively impact on the quality of life (hence the recovery process) of the patient.

Intrigued by the low profile of Italian security, I discussed the issue with the managerial staff of the institution. This was an enlightening meeting, as it gave me the opportunity to learn about the philosophy behind the definitive closure of the psychiatric hospital systems in Italy (in 2015) and the creation of the residential accommodations and to understand why things are managed the way they are. The director explained that Italian forensic-psychiatry is inspired by the Good Lives Model, the idea that the patients, given adequate support, can recover and realise a fulfilling life without inflicting harm. The Good Lives Model is grounded in the ethical concept of on human agency, the individuals’ ability to formulate and select goals, construct plans, and to act freely. For this reason a regime of “captivity” in the Italian system is deemed ineffective.

In addition, a highly restrictive setting is considered counterproductive, as the patient is held in a sterile environment (like a bubble), which is far from the reality of life in the community. Instead, the risk of relapse is potentially reduced if the person develops personal resources to deal with their condition while being immersed in a social environment. Secondly, it is believed, based on a social-constructionist model, that in a highly restrictive setting individuals learn to consider themselves as captive prisoners rather than recovering patients and for this reason they will be more likely to pose a greater safety threat. It is the mechanism of the self-fulfilling prophecy: the patients behave aggressively as they feel they are expected to do so. Treat them as human beings and they will respond accordingly is the REMS manager’s motto. This could partly explain why in the Italian system the occurrence of serious incidents is very limited, compared to high-security settings such as Rampton hospital, where the general alarm sets off on a daily basis.

The purpose of this blog is not to irresponsibly advocate for lax security measures. I am well aware that Rampton hospital hosts some of the most dangerous individuals in the country (which by the way also applies to the Italian system). I am also perfectly aware that my argument is over simplistic and based on purely observational data. The message of this blog is a different one. It is an encouragement to aspire and strive for a better system and as a researcher in forensic-psychiatry, I feel I have a responsibility in the game.

I believe there is a way of reconciling sensible security for all involved in the setting with principles of recovery, humanity, connectedness and human agency. One unequivocal way forward is information sharing. International initiatives such as the Short Term Scientific Mission (STSM) I took part in are unique opportunities for us to test the adequacy of our model of care provision. There are obvious structural differences in terms of healthcare systems, culture and policy across different countries and I do not wish to minimise them. These however, should not prevent us from looking for examples of good practice that we could integrate within our existing framework. In this sense, as a newbie in the field of research in forensic-psychiatry, I was grateful to understand the underlying principles and witness the current practices that are being experimented in the Italian REMS.

        

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