Persistent Harmful Practice in Forensic Psychiatry

Structural Violence in Forensic Psychiatry: The Harm We Do When Doing Good

Verbatim version

Dr B A Thomas-Peter



Who agrees with me that, sometimes, the organisations we work for arrange themselves in ways that make it harder to do our jobs? – That looks unanimous.

Who agrees with me that, sometimes, because of this our patients, prisoners, clients get the raw end of the deal and don’t get the service from the organisation that they need? – Also unanimous. It seems my work here is done!

It is important to establish that we agree on the fundamentals because it is difficult to speak of the subject of Structural Violence in forensic psychiatry to an audience, many of whom have dedicated much of their lives to the forensic world. I know how hard it is working with very difficult and very vulnerable people in secure conditions. It’s unrewarding for much of the time, without real appreciation by the community. The things we see and hear profoundly impact our lives in ways that we are never free of, and some of us are more affected than others.

Recently I have begun writing novels designed to help people understand the work we do, the relationship between trauma, mental health, violence and the complex web of public services that manage these. Here is the cover of my recent book, ‘The Last Truth’, which was written with Structural Violence (SV) in mind. Perhaps it also illustrates how affected I have been by the 35 years of forensic work I have accumulated. Of course I have been affected, and ‘The Last Truth’ is about excising the same demons that many of you carry.

This is my starting point

I’ve been fortunate in having a career that has allowed me so much variety. I’ve worked as an academic, clinician, manager, executive director, with inpatients, outpatients, every level of security, on three continents, across agencies, with the police in hostage situations, National Inquiries in England and Australia, advised ministry’s, worked on government working parties. I’ve ticked a lot of boxes in the forensic world, and some might say I still haven’t learned my lesson. They might be right about that.

Looking back I have remained optimistic and felt great pride in being associated with colleagues who have been smart, grounded, compassionate, innovative, resilient and sensitive. Despite this I have been left with a sense of disappointment that with all of these skills and this dedication at our disposal we never quite lived up to our potential and sometimes we have fallen well short of what was possible. But I have learned a few things in the process.

I have learned that services are not wholly bad, or wholly good, ever. There are always good people and something to fix. The issue that determines whether a service has the potential to improve has to do with the value it places on social justice for patients and the safety of staff. Neglect either of these at your peril.

I’ve learned that the most worrying services to be associated with are those that refer to themselves as “The Gold Standard”, “National Leader”, “World Class” or “Demonstrating Excellence”. There is no shortage of misplaced hyperbole in Forensic Psychiatry, but none of this impacts the care patients are likely to receive.

I’ve learned that if you really want to know how good a service is, don’t ask the people at the top, or even those doing the work at the ‘coal face’, none of whom will ever say they are doing a bad job. Instead find out how diligent the organisation is at determining and reviewing patient needs and track what the patients are actually doing in respect of having their needs met. Some years ago I created a standard for an organisation that considered itself high quality, busy and efficient. We called it The Prime Directive.

The standard went something like this, “Every patient, every day, should have one planned experience of therapy, education, recreation, or social engagement.” Fewer than 7% of patients met that goal when we started the project. We struggled to get past 40%, and then we realized why it was so hard.   We were not organised to deliver these things and we hard to start again.

I have learned that services dominated by a single individual or single discipline are failing services, who will nevertheless say they are terrific. Services that are dominated by the traditional duo of doctors and nurses will be treading water, but will mistake their drifting in and out with the tides as significant progress. Services that are truly multi-disciplinary will tell you how difficult it is to work in that way, and will never be confident they have got it right, even when they do.

However frustrated I have felt with my colleagues in the multi-disciplinary arena, I know that they are equally frustrated with me. More importantly, I know that each is a vital part of the high quality service that can be achieved together, and cannot be achieved without each of them.

Structural Violence

Structural violence is a concept borrowed by medical anthropologist Paul Farmer (1999) to focus attention on the inequity, disadvantage and suffering in respect of health. The original idea was raised by Johan Galtung (1969) who was concerned to address how organisations act, without intention, to create the circumstances of people being harmed.

Three kinds of harm emerged from Galtung’s work. The Direct kind in which a victim and a perpetrator/actor can be identified and linked by a deliberate act. Later he began calling this Personal Violence. The Indirect kind, where harm or disadvantage has occurred that may not be attributed to a particular actor, but which has arisen from the Structure and operation of the organisation. Hence the term ‘Structural Violence’. Later, he introduced a third category of ‘Cultural Violence’, by which he meant those aspects of culture …that can be used to justify or legitimize direct or indirect violence.

This approach to violence requires a more sophisticated definition, so lets start with a couple of standard approaches to defining violence and then look at how Galtung defines Structural Violence in contrast to these.

The World Health Organization (WHO): The intentional use of physical force or power, threatened or actual, that results in death, psychological harm, or deprivation.

The Canadian Public Health Association: a behavior that is diminishing, damaging or destructive. Behavior which includes sexual assault, neglect, verbal attacks, insults, threats, harassment and other psychological abuses.

These are fairly standard; deliberate, physical harm, non physical harm, actual or threatened harm.

In contrast, Galtungs definition of Structural Violence is when actual physical and psychological realizations are below their potential. Anything that causes or sustains the distance between where they are and where they could be, may be a violent act and it doesn’t matter if it is intended or not.

This idea of harm “without intention” is what makes Structural Violence easier to discuss with colleagues than other criminological discourses, which have been polarizing and blaming. Frankly, these ideas cause people to feel bad and defensive about what they do and just switch audiences off. No wonder, just look at the strap lines of this literarture!

  • “The Death of Liberalism” (Gunn 2000)
  • “The New Punitiveness’” (Pratt, et al 2005)
  • “The Veil of Liberalism” (Moore and Hannah-Moffat 2005)
  • “The New Intolerance” (Thomas-Peter 2007)

But people do get the idea that organisations are sometimes put together in ways that makes life harder to do the job you want to do. And sometimes the people we look after get the raw end of the deal because of that.

Health care provides many examples of how institutionalized processes and structures sustain the disadvantage of the vulnerable. These include:

  • Neglect of Russian prisoners suffering from tuberculosis (Farmer 1999)
  • Treating those with HIV in the USA (Farmer, Nizeye, Stulac, and Keshavjee 2006)
  • HIV prevention in Haiti (Farmer 1997)
  • Protecting sex workers in Serbia (Simic & Rhodes 2009)
  • Treatment of schizophrenia (Kelly 2005).

Healthcare is fertile ground to explore with SV, and the only new contribution I am making today is in applying SV to Forensic Psychiatry for the first time. So, let’s explore Forensic Psychiatry with a few stories to illustrate my case.

Persistent Harmful Practice in Forensic Psychiatry

Story one

In a secure mental health unit in North America, a smartly dressed psychologists and Charge Nurse showed a visitor the facilities. Off a corridor there were some offices, one room had a barred door, overlaid with plexiglass. It was dark in the room and they led the visitor to it. A middle aged man appeared at the bars. He was naked, unshaved, his hair was dishevelled and his skin gleamed with perspiration. Warm air extruded from the holes drilled in the plexiglass, carrying his garbled words and the pugent aroma of sweat and waste. They described the patient’s condition and how the unit was caring for him.

The visitor asked why the bars on the door were covered in plexiglass, and was told that the odour from the room was too much for the staff who had offices nearby. The visitor asked why the patient was naked. It was so hot in the room that they allowed him to go without clothing, providing the lights were out, to save the sensibilities of staff that might pass by. Spot the error in this picture!

This is a rare occurance and unusually insensitive but it does illustrate one important aspect that is not uncommon. Staff of all kinds, working in Forensic psychiatry and Corrections, are vulnerable to losing their ethical and moral compass because we stop seeing what is in front of us. Unsurprisingly, the organisations in which we work are resistant to change. Perhaps this is the reason why scandals emerge from hospitals after long periods of being ignored, avoided, denied or genuinely disbelieved by those who see it everyday. But here’s the thing; these organisations are staffed with health professionals, all endorsing codes of ethics and each claiming high standards of professionalism and individually claiming good intent, yet sometimes they operate in dysfunctional hospitals that perpetrate harm.

Let me posse a question to you. Is it possible that persistent harmful practice arises only from it becoming familiar, regular and being normalized? Is this the only reason why it is no longer seen with moral, professional or an ethical frame of reference? Is familiarity enough to explain moral blindness? The short answer is NO.  If you have been on an Inquiry team investigating a death or homicide in a psychiatric hospital, as I have done several times, it becomes obvious what has been known by staff at all levels, and what has been known for a very long time. It is here that Structural Violence provides a means of conceptualizing the issues, which may lead to systemic analysis of what is going on.

So, the first story tells us that familiarty is connected to ethical/moral blindness, a necessary condition for persistent harmful practice, but maybe it does not account for all of it, so let’s explore this a bit further.

Story Two

In a large multi-disciplinary group of clinicians, assembled to discuss a proposal that Clinical Teams should meet regularly, an experienced psychiatrist made a telling contribution. They said,

“The thing that I have always valued about working here is that I can come and go as I please. If we have to meet regularly as teams, I will have to consider whether I want to work here.”

It was clearly an unveiled threat, but there was a hush in the room as the implications of the contribution were absorbed.

Putting aside the admission that regular team meetings were a nuiscance, it was surprising just how candid and indiscrete the admission was. Everyone knew that having flexibility of this kind allowed some psychiatrists to collect a salary, benefit from the affiliation to the local forensic service, which was known to courts and solicitors from where they would receive private referrals, and run a thriving private business. Not everyone in the room would connect this flexibility with the poor practice that was so evident within the hospital.

You have to remember that this psychiatrist was not intending harm. They simply didn’t see it, or they failed to see that they had any responsibility for the harm. These were the conditions of employment and we know that every other discipline would defend their working conditions when challenged. That clinical teams rarely met, that care plans were not prepared or reviewed, that nurses had been abandon to get on with it, that patients languished on wards and in seclusion for long periods without plans to get them out, would not figure in that psychiatrist’s calculation. After all, technically and contractually they were doing nothing wrong, it had always been like that, so how could patients be suffering?

But momentarily, it became immoral when that privelege was exposed to a wider group as a possible cause of persistent harmful practice. Many would not have thought to questioned it prior to this and, precisely because of this, it also had resilence, which is why patients continued to suffer.

Psychologists, social workers, occupational therapists and others find lots of benefits in this situation too. There is autonomy, latitude and flexibility in organizations that do little more than warehouse patients. Without the expectation of high therapeutic standards and accountability to one’s inter-professional colleagues a quiet life can be had, or a life with the time and space to do what interests you, research, further training, private work or whatever.

The point here is that understanding personal benefits to the powerful is key to understanding the suffering of the vulnerable in forensic psychiatry. It is the second condition of persistent harmful practice.

The situation needs courageous, morally grounded and well supported leadership in order to evolve into something ethically and clinically acceptable. I have plenty to say about leadership in Forensic Psychiatry, but not the time here to say it.

Story Three

I don’t want to give you the impression that forensic psychiatry and corrections is different to other public services. That is simply untrue. The majority of people working in these institutions and other public institutions are selfless and good people wanting to do a good job, so let me take a third story from the world of post secondary education, to illustrate another facet of Structural Violence.

I had not been Dean of a Human Services Faculty for very long when, standing in line for coffee one day a young woman from my faculty stood beside me and we started talking. I knew her to be super-bright, industrious, students loved her. She told me that she was a contract faculty member and did not have a regular position. I was surprised to hear that she had been a contract faculty member for four years, and told her that there was a position available being advertised with a closing date just a few day away. Her response was deeply troubling.

She told me that she would not be applying, because she had been asked by senior colleagues not to apply for the post. She said, “That’s not how it works here. That job has been promised to someone else.” She smiled broadly. “My turn will come eventually.” She said, still smiling. “I just have to do all the ugly jobs they give me and keep my head down and I’ll get my chance.”

For any of you who have worked within a Collective Agreement of any kind, you will recognize this to be shocking. But what is the lessons here?

First, it was not shocking to her. It was just how it was. Almost invariably is it found in this work, that the powerless do not recognize their exploitation or their position of subjugation. Even if they did they tacitly accept the legitimacy of their position. Maybe it comes from being helpless to change these circumstances, but in accepting their role, they reinforce the authority of those who control access to opportunity or membership of their ‘club’. This is true of those subjected to persistent harmful practice in relation to access to medicine, education, civil liberties, human rights, whether they are citizens, prisoners, or patients.

Secondly, we can see how preferences of individuals and groups can become accepted within the culture and practice of an organisation, without official sanction.

It is also common to find those who draw power to themselves to be those who already have significant power, but want even more. This is the organizational equivelent of the Young-Laplace equation in physics that relates to the force of surface tension.

You can demonstrate this effect if you take two balloons, one big, one small join them with a tube to let air pass between them. What do you think happens? The large one draws the air from the smaller one and becomes even bigger.

In organizations there is a kind of surface tension that draws power from lesser power bubbles to the larger power bubbles. It often starts with asserting working practices that are convenient for the powerful but undermining of the work of the less powerful, claiming areas of expertise that are really shared competencies, drawing boundaries to defend, controlling access and space, eventually seeking special status; you’ve all seen it. Let’s be clear, organizations need some of this creativity and energy to evolve naturally, but sometimes it can serve the interests of staff groups and result in persistent harmful practices.

I wonder how many of you noticed in this Faculty story, in which the inflated balloons pumped themselves up at the expence of powerless, that the students of the Faculty have not been mentioned. Were they being ‘best served’ by all this? The Big Balloons would say so, but how would we know? They have a conflict of interest so their opinion can be set aside. The same dynamic exists in psychiatric hospitals, where the push and shove for influence distracts the organization from the task of careing for patients. It becomes the discussion around the water cooler and standing in the queue for coffee. It is almost unrelated to the job we do and offers no hope to those needing hope.

Not all power bubbles are unofficial or unsanctioned.

Story Four

It was Monday morning in early July at a medium size Secure Psychiatric hospital. I left my office at around 10:30 to do my usual walk around. This particular morning I was going into the rehab area but within a few steps it was obvious something was wrong. It was quiet. There were no patients, no staff. I arrived at a secure door and got my key fob out and then noticed it was already open. You can imagine what I was thinking. I moved cautiously, checking forward before opening and closing doors, a bit conscious of my footsteps echoing in hallways, and after very long few minutes, I was at the Rehab area, and still there was no-one. I walked into a large open plan office and said, “Hello”. A young woman at a desk hidden behind the door leapt six feet in the air and screamed like it was halloween!

After a few moments, when we had both recovered, I asked, “Where is everyone?”

She said, “Well not much is happening, it’s July.”

Apparently, she informed me, senior staff were on holiday and there was no qualified staff to bring patients from the ward areas, so the rehab’ areas were virtually shut down for several months.

How could it be that patients were to be stuck on ward areas for two months during the hottest part of the year, with all the implications of that?

The answer had to do with the Collective Agreement between Union and Employer. It allowed those with most seniority to have first choice of vacation dates.  So, the most senior staff all chose to have there holidays in July and August, leaving the most junior staff, the least qualified and temporary staff, if we could get them, to look after the patients. You won’t be surprised to hear that there were more security incidents, more staff injuries, more use of medication, more use of seclusion during those months, but it didn’t seem to matter.

No-one was doing anything wrong. It was all up front and agreed. Staff side and employer bargaining had signed it off together. But I wonder if anyone thought to ask the patients, or their families about about the two dire months in every year that they had to endure. What do you think?

Do you imagine that any of the families would question the incidents involving their mentally ill, encarcerated relative or the unecessary medication or seclusion used to manage them? Of course they would not make the connection, or think to question it. If they did, the family would be managed. It isn’t difficult, I’ve done it myself, as have some of you. The family would be told that we are trying our best to recruit the staff but we will draw the concern to the attention of the psychiatrist. Then the problem would go away. In the process of managing situations like this, we become part of the resilience of the mechanisms of harm.

I should say that I have been a member of the same union for about 35 years, even though I don’t live in the same country now. My commitment to organised labour is easily demonstrated, but what were they thinking of when they agreed to this? Which profession’s code of ethics would possibly condone this level of persistent harmful practice? What health executive could be content with the service being provided and harm done by such an arrangement? And yet, I discover that there is zero concern or willingness to address the matter. It is entirely invisible to the organisation. There is only one explanation of this. The patients were not important enough to be considered.

To sum up, we have persistent harmful practice arising from familiarity, plus the benefits accruing to the powerful. We’ve seen the acquiescance of the powerless and how harm to them is accepted as part of the machinery of misguided services, and sometimes not even perceived as harm by either actor or victim. It can happen informally being carried by the culture and also formally, with and without any intent. We also understand that power is hungry for more power. There are two common threads in all of this;

  • The lack of consideration of patients, and disregard for our responsibility of achieving their potiential.
  • Everyone plays a role in sustaining harm. Whether they intend to or not, Administrators, Clinicians and even Patients, in acquiesing to abuse.

Incidents and Root Cause Analysis

Two decades ago I was speaking with a consultant psychiatrist, who was a close colleague and dear friend. At the time, Public Inquiries into untoward incidents in forensic psychiatry were happening all over the UK. I had read the thirtyfive or so reports that were publicly available and I noted they all recommended similar things. The services just could not learn from each other’s mistakes. Even more alarming was that these organisations struggled to learn from their own mistakes. A conclusion arrived at ten years later by the Health Care Commission, for England and Wales.

“A common theme …. is a failure by (health service authorities) to learn from serious untoward incidents.” (Health Care Commission 2008, ‘Learning from Investigations’, page 47).

But we wondered how we would fare if one of our patients was to do something terrible. Why wait for that to happen when we could learn from all this work. So, we began looking at our shared case load as if each patient had done something terrible and a Public Inquiry was brought upon us. It was a humbling experience. Despite being a very experienced, well functioning multidisciplinary team, we found reason to critisize our efforts in every case. There was no way to avoid it.

We concluded that Inquiries will always find something to say. There is never an action, series of actions you can take that will result in the conclusion, in the event of a homicide, that everything was fine. How could they conclude that? It made us wonder what the value was of these Inquiries. What they achieved was to cause many professionals, of all disciplines, to become defensive, and many services to become preoccupied with managerialism, risk issues, defendibility, often at the expense of safety and patient care. The government started to understand the harm of these public Inquiry’s were doing and encouraged the use of locally delivered Root Cause Analysis (RCA).

RCA is a process derived from industry and part of Total Quality Management which has been applied widely in health services. Its purpose is to reveal the direct and indirect causes of incidents and what has to be done to prevent a particular incident from occurring again. The accumulated themes that emerge from a series of RCAs are useful to influence whole systems.

RCA, in one form or another, has become the ubiquitous tool around the world to help hospitals become “learning organizations”.

The problem is that it is questionable whether RCA with health is any more helpful in making us learn lessons. RCA has been described as a “highly irrational quasi-legal form of local audit” (Salter, 2003).

Writing in the British Medical Journal and reporting on the experience of hospital medicine Taitz, Genn, Brooks, Ross, Ryan, Shumack, Burrell and Kennedy (2010) conclude, “given the number of hours per RCA, it seems a shame that the final output of the process may not in fact achieve the desired patient safety improvements.” (page 1).

The danger is that RCA appears valid and credible, while often being less than that. The notion of uncovering a “root” cause adds to the gravatas, but certainly it would not meet any rigorous standard of causal evidence.

For example, where an RCA identifies a particular process or methodology having been neglected or misapplied in relation to a serious event, we have to assume that process has been properly evaluated or its probative value is known. This is rarely true. The value of risk assessment protocols are an obvious example of this. They are poor at predicting individual occurrances, their value is commonly over-estimated and typically identify huge numbers of false positives. The idea that their misapplication is a cause of an error, or the solution to preventing it subsequently, is simply ridiculous, except where there has been a deliberate misrepresentation.

It’s because of the proness to error that RCA can be used to determine outcomes that the organisation finds convenient. In good organisations, RCA might assist lessons being learned. In lesser organisations the expediant lessons can be learned.

I’m going to talk with you about just two means of manipulating an RCA, which I have encountered, that may result in overlooking the harm done to patients and consequently making changes that may make matters worse, or failing to make changes that prevent harm. There are others, but these are the most problematic. They are;

  • The bias of emphasis
  • Assuming normal capacity of vulnerable patients.

The Bias of Emphasis

Imagine an incident in which a patient with highly developed skills in martial arts is admitted to a high secure environment. He becomes violent one evening and over a period of thirty minutes smashes windows and fixtures, causes a flood, terrifies everyone and injures himself and a nurse in the process. A shocking event impacting the well being and career of a dedicated nursing professional, which could have been avoided.

The RCA considering the issues might be interested in the special circumstances of admitting an unusual patient with with fighting skills. It might be interested in communication within the hospital during an emergency and the availability of additional staff and special equipment to cope with such a frightening contingency. It might also consider the robustness of the fixtures and fittings that would have to withstand such punishment.

There might be recommedations for more training on physical and mechanical control and restraint methods, policy reviews, new staffing arrangements, or even a new special handling unit being developed. Nothing is unreasonable in this and there may be constructive and helpful outcomes arising from them.

A patient centred perspective changes the things that are important in this incident. For example, assume now that the patient had in the previous few days expressed distress at being observed through the glass window in the door to their room by a female member of staff. Being naked in unfamiliar surroundings, in addition to the patient’s mental illness, caused the important nursing task of making regular observations of patients distressing for this young person who became angry, especially angry that it occurred for a second time.

A new set of questions is posed by this, and recommendations will be very different. Why was the patient not helped to understand the purpose of observations and the need to keep him and others safe? A care plan could have been introduced to remind the patient of how things worked and to ensure each new shift of staff understood what was going on. Why was this not done? How could they have allowed the same provocation to occur for a second time? Members of the multidisciplinary team might have been asked to assist in managing the young man and perhaps shed some light on the sensitive areas of this man’s care and what they had learned about his risk to others from their assessments of him. Why were these professional resources not used? A different kind of ‘root cause’ and outcome is likely in response to these questions.

In ideal circumstances, all of these issues would be considered, but they rarely are, and there may be reasons why an RCA has one emphasis rather than the other. For example, what if the lack of communication between staff, and the absent care plans arose from unwillingness to meet regularly as a team or prepare multi-disciplinary care plans, as we saw in a previous story? This potential ‘root cause’ is very likely to emerge from a patient centred RCA but if the RCA was focused on management concerns, it might not. Similarly if it transpired that staff training in violence prevention had fallen into disuse, this is likely to emerge as a ‘root cause’ with one bias, but may be off the agenda in another.

Assuming Normal Capacity

Also ‘off the agenda’ and lost within the RCA process is the recognition that we are not dealing with conventional people of normal capacity or tolerance. Everyone who enters forensic psychiatry hospital, as a patient, is unwell and vulnerable, regardless of how belligerent and threatening their presentation is. The experience of being incarcerated for most normal people would be traumatising and acting out through fear, anger and intolerance of being told what to do all the time, would be normal. But for those with pre-existing vulnerabilities to experiencing interpersonal insult, or having not really survived psychological trauma, the impact is compounded.

It has been argued that the real effects of internalized stigma for such populations are invisible but profound. “The fact of historical marginalization is enough to make a group or individual vulnerable. When institutional structures bolster that marginalization, vulnerability is compounded…”, (Livingston and Boyd 2010).

So, when our young martial arts expert is observed by a young female nurse while masturbating in his room, for the second time in two days, he is not likely to simply feel the cringing embarassment of a normal teenager interupted by his mum. His experience will be compounded by pre-exsisting stigma and trauma, made worse by his immediate circumstances. His response, we can predict, will appear out of proportion to the provocation, but entirely consistent with his psychopathology and circumstances.

For this we don’t need a plastic bed and furniture bolted to the floor, and neither do we need to double the night staff and develop a new Violence Response Team. Instead we need to know the patient well, communicate his needs clearly among those caring for him and mitigate his risk of anger by the application of expert nursing care, supported by the wider team.

The point of this discussion is not to suggest that all of the stigma felt by patients can be accommodated, or that prior trauma is easily managed, or to imply it is unecessary to protect the public and staff from the real risks a patient may represent. It is to ask the question, where in the application of RCA to a particular incident, does a sensitivity to the impact of mental heath, of stigma, a history of trauma and vulnerability of the patient, get recognized as something we should have taken into account? It is obviously relevant to understanding incidents within a hospital, but it is generally not admitted to our Root Cause Analysis. Instead, we get vexed about having the police come and arrest the young man and having him prosecuted under the criminal code. Not surprisingly changes proposed from these investigations almost never include patient care related recommendations, and consequently harmful practice persists.

Structural Violence in Change Management

So where is this leading us? What do we do with ‘Structural Violence’? The most important way to deploy this perspective is in what we do already, when we refer to change management. I’ll offer you a thumbnail sketch of standard approaches to change management and I want you to listen for the echos of what I have been saying.

Kurt Lewin

Kurt Lewin’s work speaks of a 3-Step model, the first of which involves unfreezing the ‘quasi-stationary equilibrium’ or disconfirming the validity of the status quo by articulating the arguments for why the status quo is unsustainable. Subsequent steps employing Field theory analysis and Group Dynamics may be used to understand, power distribution and cultural dynamics. Does any of this sound familiar?

Prochaska’s and DiClemente Trans-Theoritical model of change

The ‘Pre-contemplation’ and ‘Contemplation’ stages in Prochaska’s and DiClemente’s model of readiness for change, invites managers to determine the extent to which people see the problem, the need for change or their willingness to contemplate alternatives, as a measure of resistance to change.

Hinings and Greenwood’s model of change dynamics

Hinings and Greenwood’s model of change dynamics looks at change possibility within the interplay of five factors: situational constraints, interpretive schemes, interests, dependencies of power, and organizational capacity.

Pettigrew’s Context/Content/Process Model

Pettigrew’s model posits that the prospect of change should be analyzed based on three dimensions of Context, Content, and Process. In the first dimension of Context, we should appraise structures, culture, power distributions, skill base, and resources, reflect much of what we have mentioned within SV.

The point I am trying to make here is that there is nothing radical, outlandish, rebellious, eccentric, outlying or paranoid about inviting SV into our analysis of organizations and our efforts to change them. The issues I’ve raised lay at heart of every change management model I have encountered, even the wishy washy ones prepared by public services determined not to offend anyone.

There is only one thing preventing it from have the impact it should rightly have in reforming Forensic Psychiatry where it need reforming. It needs to be admitted to our consciousness.


Galtung once noted that we are not inclinded, as a species, towards Structural Peace. Peace, it seems, is not a stable state, and we have to work hard to prevent ourselves returning to the feudal dominance of the few over the many, and especially the already powerful over the already powerless. In public service our obligation is to those in need and the safe care of those meeting that need. To achieve that we have to overcome our retiscence, not just to admit the concept of SV to consciousness, but also our retiscence to change thoughts and actions that sustain it. In other words, we have to;

  • Work to written Standards of clinical care in a Multidisciplinary way, being accountable to, and valueing each other.
  • Acknowledge personal Benefits to individuals as distorting influences in health care.
  • Learn from Mistakes and remove bias from RCA’s.
  • Be reflective about Our Role in the conduct of our patients and the context we make for them.
  • Value the Powerless and put patients at the forefront of our considerations; not just some decisions, but all of them.

The single most important observation of secure forensic psychiatric hospitals in respect of patient safety, is their potential to harm the patients they are responsible for.

It’s the tolerance of this situation that is most troubling. There cannot be a professional training program or regulatory body anywhere in the world that would countenance such inaction. What discipline would be proud to let things be? Yet it is these groups, these professionals, that must make changes and introduce social justice to the heart of clinical care, without which codes of conduct and professional ethics mean nothing. Let me unpick that a little to demonstrate a major obstruction to making changes to organizations that are failing to help patients achieve their potential.

Most ethical frameworks include the notion of ‘Do no harm’ and commonly this is interpreted as applying to the individual client. The issue here is limiting your responsibility of ‘doing no harm’ to that ‘individual’ and each subsequent ‘individual’.   Without intention it has become the mechanism used by clinicians to absolve themselves from being responsible for influences that will harm a group or a class of patients. I’m suggesting that this perspective is not ethically acceptable in a secure hospital where a whole class of disadvantaged and powerless individuals are impacted by a culture that no clinician accepts any responsibility for and yet they act, or fail to act, so as to sustain it. It is neither reasonable or just that we are limited in this way.

The challenge in forensic psychiatry is about being clinically and ethically responsible for the collective wellbeing of a class of patients while they reside in secure hospital and are rendered vulnerable by their history, their designation and circumstances. Until this responsibility becomes operationalised into the contractual obligations of all our executives, managers and clinicians in forensic psychiatry, there will be moral blindness, self interest, suppression of information, distortion of organisational processes and harm to patients.

What I hope you go away with today is, that it doesn’t have to be that way. You have the tools to change it, but first you must admit the prospect of SV into consciousness and then have the courage to act out of that conscience. Of course you must solve problems as they arise, but try not to do it with operational pragmatism, but with social justice and safety of staff in mind. Expect it to be difficult. You will be resisted by everyone with power and misunderstood by all those you are trying to help, but it is what the highest professional standards expect of us.

Good luck.

Thanks for listening.



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