This essay describes lived-experience based strategies for persons with mental illness who offended (PMIO) and their families. These recommendations are derived from the results of a multidisciplinary research project which aimed to develop multidisciplinary strengths-based strategies for PMIO and their families.^1,2 These recommendations can inspire a broad range of practitioners and policy makers from the criminal justice system as well as the mental health systems working with PMIO and their family.

Diversion of persons with mental illness who offended

There is a plurality of criminal justice responses to PMIO across countries and continents. One way of responding to PMIO is subjecting them to court-mandated treatment which is typically combined with ongoing judicial supervision.³ Court-mandated treatment programs for PMIO aim at reducing recidivism and improving mental health outcomes in PMIO by referring them to judicially supervised treatment and services instead of imposing traditional criminal justice responses, such as prison or jail sentences.⁴ Judicially supervised treatment for PMIO may involve residential treatment such as detainment in or admission to a forensic psychiatric hospital and/or community programs such as specialized probation services and forensic assertive community treatment. The goal of court-mandated treatment is therefore twofold: the protection of society, and the provision of treatment as well as support for the individual. While both care and control are necessary to attain the goal of court-mandated treatment programs, their focus, as well as the focus of inter-agency collaboration between the criminal justice system and the mental health system has traditionally been primarily on controlling risk.⁵

Strength-based approaches gather momentum in forensic mental health care

As a supplementary counterbalance to risk-based approaches, strengths-based approaches gather much more momentum in the broad field of forensic mental health care. Strengths-based approaches are characterized by the following six principles: 1) people with mental illness (and other issues) and their social network (such as partners, family and friends) can learn, grow and change, 2) the focus is on the individual and contextual strengths rather than (exclusively) on deficits, 3) the community is viewed as an oasis of (natural) resources, 4) the client directs the change process and defines (personally meaningful) goals, 5) the relationship between the recipient and the professional is essential and hope-inducing, and 6) the primary setting for strengths-based practice is the community or the natural environment of the recipient instead of the office.⁶ Examples of strength-based approaches in forensic mental health care are the desistance, the recovery, and the human rights paradigms. These paradigms differ regarding their substantive focus but share the value they attach to strengths, capabilities, human dignity, participation, connectedness, and inclusion.⁷

A lack of attention to the voices of persons with mental illness who offended and their family members

In general, the voices of PMIO and their families are lacking in terms of debates about ‘what works’ and how in court-mandated treatment. Yet, contextually, this lived-experience or real-life evidence is important for the development of relevant practice and policy.^8,9 In research, the strengths and capacities of PMIO and their family members can be acknowledged by centralizing their lived experiences during the research process. Thereby the scientific, outsider approach to care is fused with a subjective, insider approach to care, which has also been recommended by the World Health Organization.^10,11 Qualitative research, which focuses on subjective experiences and meaning making of individuals, is well suited to gaining insight into how outcomes and processes can be explained.¹²

Lived-experience-and-strengths-based recommendations of persons with mental illness who offended and their family members

The current multidisciplinary study is connected with strengths-based approaches across different disciplines, namely procedural justice, desistance, recovery and family support.⁷ The study was carried out in Flanders, the Flemish-speaking part of Belgium.

Thirty-three family members,¹ i.e. mothers, fathers, brothers, sisters, uncles, antes, and daughters of PMIO, participated in the study in terms of family support. This study consisted of semi-structured interviews and family support groups.

In total, 286 PMIO who were subjected to court-mandated treatment with an indefinite duration participated in focus groups and semi-structured interviews as part of the studies on procedural justice, desistance, and recovery. At the time of the study, these participants were incarcerated, were admitted to forensic or general inpatient psychiatric services, were supported by forensic or general outpatient psychiatric or social services, were supported by in- and outpatient services for persons with a mental disability, or were already definitely released into the community.

The following lived-experienced-and-strengths-based recommendations are based on the results of these four qualitative studies. These recommendations can serve as inspiration for professionals in the mental health system as well as for professionals in the criminal justice system.

A humane and high-quality approach

PMIO and their family members want to be approached as human beings, and not as ‘criminals’ or ‘numbers’. Professionals who treat them with respect, have faith in them and trust them are important. Someone who believes in them would also support them in believing in themselves. Being approached in a humane and high-quality manner can offer an antidote to (self) stigma. A negative approach by professionals can echo previous experiences of stigma and exclusion. PMIO and their family members appreciate professionals who listen actively, show genuine care, make time for them, and are ‘really there’ for them.

In order to fully comprehend PMIO and their family members, formal interactions – such as treatment sessions, appointments with probation officers, and judicial hearings –, should be accompanied by informal and spontaneous interactions. Examples of informal and spontaneous interactions can consist of: going on an excursion together or completing household chores together. Professionals should be present around PMIO and their family members. Recovery and desistance-oriented practices recognize that daily life offers real-life opportunities for learning and positive experiences.

Active involvement

PMIO and their family members want to be actively involved with court-mandated treatment. They are often not involved in the decision-making processes. It is important to listen actively to what they have to say and initiate true dialogues instead of alternating monologues, and by asking in-depth questions. Family members are often searching for a shared partnership with the providers of treatment so they can jointly share information and advice.

Listening is important but of equal importance are their needs, desires, concerns, and insights being taken into account. Consequently, (mental health) care and support programs and conditional release conditions can be individually tailored. Participation is important on a substantive level (e.g. the content of a daily schedule, treatment sessions, conditional release conditions) as well as on a formal level (e.g. the different stages and goals of treatment over time).

Transparent communication

Transparency and information sharing are preconditions for active involvement. PMIO and their family members are often not informed about the different aspects of court-mandated treatment. Written information is necessary and useful, however it is insufficient. Oral communication and the possibility to ask questions as well as express concerns are vital. Oral and written communication should focus on both general and personalised information.

In the beginning as well throughout the court-mandated treatment trajectories understandable information should be continuously provided to PMIO and their families. This information should consist of the significance, meaningfulness, usefulness, and continuity of treatment, of conditional release conditions, of ward rules, of treatment agreements, or of any other relevant aspect considered important to PMIO and their families.

Decision-making processes should be transparent, and decisions of professionals should be explicitly motivated. Expectations and concerns of professionals should be clearly communicated so that PMIO and their family members are aware of the requirements for successful completion of court-mandated treatment.

Individualized care and support

A balance should be maintained between giving attention to the individual needs of PMIO and to the societal needs, as well as between care and control. Treatment goals and conditional release conditions should be tailored to the needs of the individual instead of relying on one-size-fits-all goals and conditions. Treatment should cover more subjects than merely criminal offenses and past issues. Themes such as self-reliance and trauma are examples of important topics for PMIO.

The treatment method should also be a meaningful experience for PMIO. First, an appropriated balance between individual and group treatment opportunities should be provided. Second, periods of rest and tranquility should be provided during court-mandated treatment trajectories. During these periods, PMIO can strengthen and perpetuate their recovery. Third, (obligatory) living in shared residencies can be a stressful experience. Living together in smaller groups can bring some relief.

Control does not have to disappear. Some types of control can be helpful for PMIO, as long as control does not become coercion. Examples of ‘helpful control’ are personalized conditions and shared decision making. Examples of ‘coercive control’ are high levels of pressure to perform and forced admission to treatment services.

Gradual reintegration

Societal exclusion processes can be repeated on the level of mental health care when all care and support is provided within one facility. This thereby precludes social and professional interactions with persons not affiliated with the facility. Existing social contacts outside of the facility should be retained as much as possible. For instance, by allowing PMIO employment in the community even if they are admitted to a (forensic) psychiatric hospital, or by cooperating with the neighbourhood or community in order to initiate, stimulate or reinforce contacts between neighbourhoods or the community and PMIO.

Working towards re-integration into the community should start as soon as possible during a court-mandated treatment trajectory and not be postponed until the final phase of admission in a (forensic) psychiatric hospital or ward. The reintegration process should be incorporated into every phase of a treatment trajectory. During this trajectory, PMIO should be able to acquire incremental liberties and gradually re-integrate into the community.

A gradual reintegration provides perspective, hope, and incremental progress. It should be supported and guided by professionals. One on one guidance by a professional is preferred over group activities in the community. If possible and if it is deemed to be desirable, along with the consent of PMIO, the family should be involved from the start of the reintegration process as they can play an important role in actual reintegration.

Quality of life: daily activities, social network, housing and finances

It is important to focus on high-quality social contacts, meaningful daytime activities and work, and stable housing and income because these are often lacking in the lives of PMIO. Targeting these life domains enables reintegration into the community. It should be stressed that the quality of these factors is more important than simply their presence.

Employment and volunteer work have multiple functions: having an occupation and developing and extending a social network. In order to provide meaningful daily activities, consultation and discussion with PMIO are necessary.

Existing social contacts are often lost during (indefinite or lengthy) court-mandated treatment trajectories. Out of necessity, friendships are often only initiated with PMIO. Therefore, treatment providers should encourage and support the development and expansion of the social network of PMIO. Special attention should be paid to getting family members involved, and to including the neighborhood and the community in facilitating social acceptance.

Contact with ‘companions by experience’ should be encouraged within and across facilities. This companionship should be tailored to the needs and expectations of PMIO. ‘Experiential knowledge’ and the sense of ‘being companions by experience’ can emerge from different perspectives: some PMIO feel connected when they are able to exchange experiences about the criminal offences they have committed, others want advice and to discuss their legal status, and others feel connected because they have the same mental illness. However, a social network should not be restricted to contacts with ‘companions by experience’.

(Future) housing and finances are also important. Stability, support, consultation, and discussion are as important in terms of these life domains.

Indefinite forensic psychiatric treatment as a mortgage?

An indefinite duration of court-mandated treatment weighs heavily on PMIO and their family members. Two recommendations can counterbalance this experience. First, a target date should be provided together with clear (sub)goals that should be attained by PMIO in order to be definitively released into the community. Second, transferring PMIO back to prison in case of non-crime related incidents should be avoided. If release conditions are violated, figure out why they are breached in discussion with PMIO. In doing so, the underlying causes of breaches can be dealt with.

Doing research with persons with mental illness who offended and their family members

A humane and high-quality approach towards PMIO and their family members is also a recommendation for researchers and academics. With this kind of approach, research participation can be experienced as pleasant, valuable and useful. It fosters the development of a trusting relationship between a (qualitative) researcher and a participant. Researchers should not be fearful of proximity. As well as being researchers they should also just be human beings, and have authentic interactions with participants. They should also have an informal chat after the interview.

Researchers should not only approach PMIO and their family members as human beings but also as ‘knowledgeable’ human beings. Researchers should inherently value their experiential knowledge. In this respect, researchers should also be reflexive regarding their preconceptions and attentive to participants’ corrections.

Listening to and confronting the life stories of PMIO and their family members is not always easy. Their narratives were characterised by strength, resilience, combativeness, life wisdom, hope, perseverance, and love. Their life stories, however were also characterised by injustice, powerlessness and hopelessness. Specifically, the lack of informal and formal care and support as well as the excess of trauma and stigma was striking. Therefore, it is also important to provide formal and informal opportunities for researchers to debrief the participants.

Conclusion

The voices of PMIO and their families were centralized in this multidisciplinary study designed to develop multidisciplinary strengths-based strategies for PMIO and their families. Their knowledgeability is clearly reflected in the recommendations based on their experiential knowledge. Taking these recommendations into consideration can add a holistic and solution-focused approach towards PMIO and their families.

It is 6 October 2005. I step along in my new crocs. Over the next few years, they will carry many positive and negative things with them. Over the course of a seemingly endless way, I wear the same crocs. The final result is that I still have them, my crocs, and that I am still standing steady in them. I do not stand in the crocs now – I am standing in daily life. My crocs knew a lot of emotions. Metamorphoses. I have repeatedly pulled myself up by the crocs, because I started to do things with them during my long admission. I went with them everywhere. Haha, to give only a small example: I walked in my crocs even to the market. I went so far that the crocs have become an image of myself. During my experience with moments of stress, my toes curled in them. I sweat inside them. You cannot imagine how strong my crocs were the day I went back to society. To give a new direction to my life, I stepped away from my old, worn-in crocs. I immediately bought a new pair. I wear these daily now. Since 4 August 2014, I walk with them in my home city. I live there in the privacy of my happy and wonderful family. It is certainly worth it to make the step and to see where you get in life. Of course, it is with ups and downs, but you learn a lot from the downs. I can testify to that. My daily life has turned around 360 degrees. The crocs have endured the process of getting Clean very well. Now I am still Clean. You have to be strong for that in daily life. These new crocs also carry this strength in my being. I am very happy to have bought this new pair. I alone have done this and no one did it for me. I have received advice and much support from my local environment. For that, I sincerely thank my wife and kids, my family, and the small group of friends that I have built up.

The Authors

Ciska Wittouck is a clinical psychologist and criminologist, and currently works as a postdoctoral staff member at the department of Criminology, Criminal Law and Social Law at Ghent University. Her research focuses on vulnerable groups in society and in criminal justice and mental health systems, strengths-based practices, procedural justice and legitimacy, and (innovative) qualitative research methods.

Freya Vander Laenen is an associate professor in Criminology at Ghent University. Her research focuses on vulnerable persons (because of substance use, mental illness, social exclusion) in contact with the criminal justice system, and she has long standing experience in research on drug policy, drug prevention, drug treatment, and harm reduction.

Stijn Vandevelde is an associate professor in Special Needs Education at Ghent University. His research interests include forensic special education; the support of mentally ill offenders (with an intellectual disability); persons with intellectual disabilities and co-occurring behaviour problems and/or psychiatric disorders; and rehabilitation of offenders (e.g. underpinned by the Good Lives Model).

Sara Rowaert currently works as a postdoctoral staff member at the department of Special Needs Education at Ghent University. Her research focuses on family recovery and experiences as well as support of family within forensic mental health care.

Natalie Aga obtained a doctoral degree in Educational Sciences at Ghent University. Her research focuses on recovery needs and resources of persons labelled not criminally responsible and on lived experiences of persons with mental illness or intellectual disability who offended. She currently works as a lecturer and researcher at the Thomas More University College of Applied Sciences, Antwerp, Belgium.

Sofie Van Roeyen obtained a doctorate in criminological sciences at Ghent University. Her research interests include desistance, recovery, mentally ill offenders and forensic psychiatry with a particular focus on lived experiences.

Kurt Audenaert is a part-time senior full professor in Psychiatry and Criminology at Ghent University. His research focuses on aggression and transgressing behaviour, neurobiology and neuro-criminology.

Wouter Vanderplasschen is associate professor at the Department of Special Needs Education at Ghent University and is a senior researcher in the field of substance abuse treatment and recovery. His research interests include addiction recovery, case management, treatment methods, vulnerable groups, therapeutic communities, continuity of care and evaluation of treatment.

Tom Vander Beken is a senior full professor in Criminology at Ghent University. His research focuses on criminal justice related issues in an international and comparative perspective, and often has special focus on vulnerable persons (e.g. mentally ill offenders).

References

¹ This project was funded by Ghent
University (BOF14/G0A/006). The research focused on family members who still have some sort of contact with their relative. However, we are well aware of the fact that some family members also have no or a troubled relationship with their relative. Therefore, when addressing family members of PMIO, it is important to take the heterogeneity of family members into account.

² Aga, N., Audenaert, K., Nollet, L., Rowaert, S., Schipaanboord, A.E., Vander Beken, T., Vander Laenen, F., Vanderplasschen, W., Vandevelde, S., Van Roeyen, S., & Wittouck, C. (2019). Powerful narratives. The internment measure in a different light. Gompel&Svacina: Oud-Turnhout/’s-Hertogenbosch.

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⁹ Livingston, J. D. (2018). What Does Success Look Like in the Forensic Mental Health System? Perspectives of Service Users and Service Providers. International Journal of Offender Therapy and Comparative Criminology, 62(1), 208-228.

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¹¹ World Health Organization. (2018). European Health Report. Highlights. Geneva, Switzerland World Health Organization.

¹² Gergen, K. J., Josselson, R., & Freeman, M. (2015). The Promises of Qualitative Inquiry. American Psychologist, 70(1), 1-9.