Received: 13 August 2018 Accepted: 28 August 2018

DOI: 10.1002/cbm.2090

INVITED EDITORIAL

Recovery and forensic care: Recent advances and

future directions

1 | I N T RO DU CT I O N

“Secure recovery”—the application of recovery‐oriented principles to the practice of forensic mental health care—is
becoming more widespread. In 2011, we wrote an editorial introducing its conceptual framework and the unique chal-
lenges arising when bridging principles of recovery with secure care (Simpson & Penney, 2011). At that time, the con-
cept of secure recovery was in its infancy, with almost no empirical literature on its validity, reliability, or clinical utility.
It is pleasing to see that, since 2011, there has been extensive work exploring recovery‐oriented themes in quantitative
and qualitative studies with forensic service users, their family members, and forensic mental health staff.
The often complex nature of recovery among forensic mental health service users is now more amenable to
empirical investigation, given the increasing conceptual clarity about recovery principles in general and the availability
of tools to measure its experience and progress from the non‐forensic literature (e.g., Burgess, Pirkis, Coombs, &
Rosen, 2011). Recovery‐oriented tools specific to forensic settings, however, are still lacking. Shinkfield and Ogloff
(2014), in their review of forensic outcome tools, found six candidate tools to measure clinical progress in forensic
mental health, including two which are recovery tools originating in general mental health—the Illness Management
and Recovery Scales (Mueser et al., 2004) and the Mental Health Recovery Measure (Bullock, Wuttke, Klein,
Bechtoldt, & Martin, 2002; Young & Bullock, 2003)—and one designed specifically for forensic settings—the recovery
subscale of the Dangerousness, Understanding, Recovery, and Urgency Manual (DUNDRUM; Davoren et al., 2013).
The dominant assessment paradigm, however, is still one of violence risk, and measured outcomes continue to be
focused on adverse events such as violence, substance use, and criminal recidivism (Chambers et al., 2009). We still
know too little about the prevalence of strengths‐based factors and successful outcomes experienced by offender‐
patients as they recover and move out of secure care (Livingston, 2018; Simpson et al., 2018).

2 | PAT I E NT E X P ERIE NC ES OF SE CURE RE C OVE RY

Several studies have now identified key principles of recovery as expressed by forensic mental health service users
(e.g., Drennan & Aldred, 2012; Drennan & Woolridge, 2014; Livingston, 2018; Livingston, Nijdam‐Jones, Lapsley,
Calderwood, & Brink, 2013; Nijdam‐Jones, Livingston, Verdun‐Jones, & Brink, 2015), including two reviews (Clarke,
Lumbard, Sambrook, & Kerr, 2016; Shepherd, Doyle, Sanders, & Shaw, 2016). Clarke et al. (2016) conducted a sys-
tematic review and narrative synthesis of the 11 qualitative studies on offender‐patient perceptions of personal
recovery, identifying six super‐ordinate themes: connectedness, sense of self, coming to terms with the past, free-
dom, hope, health, and intervention. The themes of connectedness and sense of self were noted to be especially
salient, highlighting the importance of positive relationships with family and staff as facilitators of recovery. There
was an important connection between the presence of nurturing relationships and the process of self‐discovery. Fur-
ther, opportunities to develop a sense of self that was separate from the “offender identity” was deemed critical to
recovery, while the loss of individuality experienced during hospitalisation was discussed as an impediment.

Crim Behav Ment Health. 2018;28:383–389. wileyonlinelibrary.com/journal/cbm © 2018 John Wiley & Sons, Ltd. 383
384 INVITED EDITORIAL

These themes overlap and extend the findings of Shepherd et al. (2016), who synthesised five of the same stud-
ies included in the Clarke et al. (2016) review. They identified three major themes as supporting the recovery process:
hope and social networks, a personal sense of safety and security (provided by the physical environment, relation-
ships with care providers, or both), and identity work (making sense of past experiences, understanding the role of
disorder, and constructing a sense of self). While these themes overlap in important ways with key principles of
recovery identified in the broader mental health literature (Mental Health Commission of Canada, 2009; Repper &
Perkins, 2003), they highlight a particularly important area for offender‐patients around safety and security and
the need to come to terms with the past, understandably salient in the light of the disproportionally high rates of
childhood abuse and trauma among them (Garieballa et al., 2006; Spitzer, Chevalier, Gillner, Freyberger, & Barnow,
2006) and the hazardous and often devastatingly traumatic nature of their previous offending.
The importance of interpersonal connection as a facilitator of recovery is a strong and recurring theme among
offender‐patients. In a study of 30 forensic inpatients, Nijdam‐Jones et al. (2015) found five major factors that were
perceived as facilitating or hindering recovery: involvement in programmes, belief in rules and social norms, attach-
ment to supportive individuals (family, friends, and staff), commitment to work‐related activities, and length of stay
in hospital. By contrast, the stigma and isolation which may be associated with forensic hospitalisation were noted
to disrupt these key attachments and, with uncertainty surrounding the length of hospital stay and associated
feelings of hopelessness, potential impediments to recovery.
Most recently, Livingston (2018) interviewed 18 forensic mental health service users and 10 service providers,
with the aim of understanding how the concept of “success” is characterised in the forensic mental health system.
Participant responses suggested multiple forms of success across six different domains: the ability to lead a normal
life, an independent life, a compliant life, a healthy life, a meaningful life, and a progressing life. Relevant markers
of success (e.g., health, meaningfulness, and normality) were thus much broader than outcomes related to an absence
of violence or recidivism, or “cure” of the mental disorder(s). While participants acknowledged the relationship
between violence control and the protection of public safety, their values went beyond recidivism risk management.
Recovery for offender‐patients encompasses not only features of general recovery, such as hope and optimism,
re‐establishing a positive identity, and building a meaningful life despite illness, but also specific offence‐related
recovery, which includes coming to terms with the offence and not reoffending or being taken as a re‐offender. This
fits well with the conservative optimism of forensic mental health practitioners who are concerned to work with the
challenge of reconciling a sense of personal guilt or responsibility on the part of the offender‐patient with the impair-
ments conferred by mental illness (Dorkins & Adshead, 2011; Drennan, Law, & Aldred, 2012; Moore & Drennan,
2013). The emerging themes of safety and security (Shepherd et al., 2016) are of importance considering that insti-
tutional obligations to maintain physical security have been cited as barriers to fully embedding recovery‐oriented
principles in forensic settings. Drennan and Woolridge (2014), however, noted that security requirements such as
restrictions of movement or compulsory treatment may, paradoxically, create an environment of safety and predict-
ability in which the first steps towards recovery become possible. A person cannot begin to recover while still either
perpetrating or being victimised by violence, so the safeguards offered within secure hospital units may be a neces-
sary prerequisite for (rather than a barrier to) first steps towards recovery. Similarly, coercive interventions such as
the administration of medication against someone's expressed desires may be necessary to initiate the recovery
process and regain the capacity to collaborate in treatment decisions (Geller, 2012).

3 | S T A F F A T T I T U D E S T O W A R D S SE C U R E R E C O V E RY

Given the centrality of interpersonal connectedness as a facilitator of recovery, staff attitudes and experiences are
crucial to adopting a recovery‐based approach for offender‐patients. Earlier studies suggested that some such staff
perceived a fundamental incompatibility between recovery principles and secure care (e.g. promoting autonomy
and self‐determination under conditions of legal coercion; Drennan et al., 2012). Further, a perception among some
INVITED EDITORIAL 385

service providers of the hospital as an unsafe environment could encourage limiting practices aimed at containing
risk (e.g. seclusion and restraint) rather than engagement with patients (Livingston, Nijdam‐Jones, & Brink, 2012). It
has also been cautioned that introducing recovery principles into forensic mental health services may be perceived
by staff as tokenistic or as “yet another training” that brings with it additional paperwork (Eunson, Sambrook, &
Carpenter, 2012).
More recently, however, three studies of staff attitudes have found more encouraging results. Chandley et al.
(2014) described an innovative project applying recovery principles within a high security hospital setting, which
addressed any perceived contradictions staff experienced in the application of a recovery‐based approach. McKenna,
Furness, Dhital, Park, and Connally (2014) studied the themes that emerged from nursing staff efforts to transform a
secure model of care into a recovery paradigm, noting the centrality of having a clearly enunciated philosophy of care
and a manual to support it. While reporting on the feasibility of this approach, they also emphasised the importance
of ongoing education, reflective learning, and leadership. Niebieszczanski, Dent, and McGowan (2016) used grounded
theory analysis to explore hope and recovery from interviews with 10 nurses in a medium security hospital service.
Personal beliefs around hope and the importance of team atmosphere in enhancing nurses' ability to promote realistic
hope within patients formed the core concerns. Further noted was the emotional impact on nurses in performing this
work, and the importance of support to assist staff in managing the emotional demands of their work and maintain
this hopeful approach.
These recent findings support earlier work suggesting that the therapeutic alliance between patient and staff is
the key common ground between effective security and effective treatment (Bressington, Stewart, Beer, & MacInnes,
2011; Coffey, 2006; Hamilton, 2010) and, more broadly, attest to the essential congruence between adopting
recovery principles into care and reducing patient risk. The therapeutic relationship is consistently noted as central
and catalytic to the recovery process, one of the strongest factors associated with user satisfaction in forensic mental
health services (Bressington et al., 2011; Coffey, 2006) and predictive of treatment outcomes (Horvath, 2000). Poor
engagement has been reported as having negative effects. (Barnao, Ward, & Casey, 2015), in a study of 20 forensic
patients in New Zealand, found that negative evaluations related to high staff turnover and a disproportionate focus
among staff on mental illness and risk; patients described inconsistent and uncoordinated approaches to their
rehabilitation and a lack of person‐centred care. Such experiences, resulting in a sense of powerlessness, lack of con-
trol, and loss of identity, have previously been reported in other studies (Farnworth, Nikitin, & Fossey, 2004; Hörberg,
Sjögren, & Dahlberg, 2012).
These findings underscore the primary importance of effective staff‐patient relationships to the recovery process,
consistent with the themes of connectedness and social support networks emerging from the Clarke et al., (2016) and
Shepherd et al., (2016) reviews. Attempts to build trusting and “hope‐inspiring” relationships (Perkins, 2006) from the
outset, in addition to having a reasonable degree of consistency in staffing, appears critical, as does having staff adopt a
transparent, personalised and strengths‐based approach to care planning and risk assessment.

4 | R I S K A S S E S S M E N T A ND M A N A G E M E N T WI T H I N TH E R E C O V E R Y
MODEL

How do we perform the core processes of risk assessment and risk management—so fundamental to working with
offender‐patients—in a recovery‐oriented manner? Factors related to the index offence and the generally hostile
social and political climate within which forensic mental health service users reside may constitute unique challenges
with respect to their recovery. There is always risk of “deep” social exclusion and double stigmatisation on account of
their mental illness and offence history (Mezey & Eastman, 2009; Simpson & Penney, 2011). Best practices in risk
assessment and management have, in fact, evolved with recovery principles.
Perhaps the most significant advance in this respect has been the promotion of shared decision‐making (SDM)
models (e.g., Barker, 2012; van den Brink et al., 2015). Although these models have been advanced primarily in
386 INVITED EDITORIAL

general psychiatry (Drake, Cimpean, & Torrey, 2009; Hamann, Leucht, & Kissling, 2003) and in relation to medical
treatment decisions (Joosten et al., 2008), their applicability to risk assessments in forensic mental health is increas-
ingly recognised (Barnao, Ward, & Robertson, 2016; Coffey, 2012; Dixon, 2012; Sullivan, 2005). There is now a small
body of research suggesting that service users do understand the concept of risk as it pertains to their own lives and
that inclusion of their perspectives adds valuable information to the risk assessment and management process. For
instance, Fluttert, Van Meijel, Nijman, Bjørkly, and Grypdonck (2010) reported on results of a novel risk management
method involving a collaboration between patients and nurses to identify early signs of aggression and generate
preventive actions. This method was shown to reduce the number of seclusions and the severity of aggressive
incidents in a maximum security hospital setting.
In a similar vein, Davoren et al. (2015) developed a patient‐rated version of their risk and recovery toolkit
(DUNDRUM), to supplement the earlier staff‐rated form (Davoren et al., 2013). Staff and patient ratings were found
to be significantly and positively correlated, although patients generally rated themselves as at lower risk and further
along in their recovery than did staff. Patient self‐ratings were also found to lack precision (with respect to their
actual level of security within the hospital) and placement predictive accuracy (movement to lower levels of secu-
rity/discharge to the community). Of particular interest and importance, however, agreement between staff and
patients increased as patients progressed further along their rehabilitation pathways. Further, this improved concor-
dance was predictive of movement towards lower levels of security and eventual discharge (Davoren et al., 2015).
Similar results were found by van den Brink et al. (2015) who sampled 201 outpatient forensic mental health ser-
vice users and their case managers and assessed patient‐staff concordance on key risk and protective factors
appearing on the Short Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, &
Desmarais, 2009). While agreement was good at the service user and staff group levels, the level of concordance
between individual patient and case manager pairs was poor. Case managers were found to be moderately less pos-
itive about patient functioning compared to the patients themselves. Despite this, when the predictive validity of
patient and case manager risk assessments was examined, the optimal outcome model consisted of the case man-
ager's structured professional risk estimate in combination with the patient's self‐appraisal on the START.
Results suggesting suboptimal concordance and predictive validity of patient self‐ratings is the perhaps the
expected outcome of a tradition of doing risk assessments “to” rather than “with.” It is both an obvious and clinically
intuitive suggestion that making risk assessment a collaborative enterprise should make it less opaque and help to
promote patient empowerment, engender trust and promote therapeutic engagement (Barker, 2012). The commit-
ment to understand and prevent repetition of harmful behaviours is a key recovery goal that could increase patient
motivation to work on these areas of life and contribute to an understanding of these behaviours as contrary to
building a successful life. As noted within the Good Lives Model of offender rehabilitation (Ward & Maruna,
2007), individuals may have limited motivation to participate in risk management plans that emphasise avoidance
goals and which are not linked to values and aspirations that are important to that individual (Barnao et al., 2015).
A collaborative approach to risk assessment and management would ensure that these formulations are both relevant
and understandable to the service user, thereby encouraging a deeper understanding of risk issues and mastery to
desist from harmful behaviour. This still, however, needs empirical testing—research which should be prioritised
given the prominence and consequentiality of risk assessments in forensic mental health practice.

5 | F U T U R E D I R E C T I O N S F O R R E S E A RC H A N D S E RV I C E S

The concept of secure recovery has gained considerable acceptance within forensic settings internationally since the
mid‐2000s, and both patient and staff perspectives have been explored. The potentially distinct needs of offender‐
patients related to their offending and trauma are, however, less well studied. These unique domains of needs are
missing from current recovery measures and point to the need for further development of offender‐patient‐specific
recovery support tools. What is also clear from studies of service users is that relationships are central facilitators of
INVITED EDITORIAL 387

recovery. Here, there is an emergent literature on how staff may work collaboratively towards secure recovery, cov-
ering their personal attributes, clarity of purpose, team work, and leadership. Linked to this is a small literature looking
at shared models of decision‐making as applied to risk assessment and management, including tools to structure col-
laborative engagement around risk understanding. Much more such work is needed.
Working with patients in recovery in forensic mental health settings is complex, but rewarding. The next phase of
forensic recovery research must be conceptual, practical, and longitudinal so that we may understand what improves
patient outcomes and delivers more effective and respectful services. And there is much to guide services now in
innovative service development and recovery informed approaches to care.

ORCID
Alexander I.F. Simpson http://orcid.org/0000-0003-0478-2583
Stephanie R. Penney http://orcid.org/0000-0002-5890-4163

Alexander I.F. Simpson

Stephanie R. Penney
Department of Psychiatry, Centre for Addiction and Mental Health and University of Toronto, Toronto, Ontario, Canada

Correspondence
Alexander Simpson, Forensic Division, Department of Psychiatry, Centre for Addiction and Mental Health and University of Toronto, 1001
Queen Street West, Toronto, Ontario M6J 1H4, Canada.
Email: sandy.simpson@camh.ca

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How to cite this article: Simpson AIF, Penney SR. Recovery and forensic care: Recent advances and future
directions. Crim Behav Ment Health. 2018;28:383–389. https://doi.org/10.1002/cbm.2090