Sentenced to care - punishment or opportunity?

"What separates many of our patients from most other people in psychiatry is that they have a very complex clinical picture with multiple problems. Many of our patients have several problems in addition to the basic illness, such as substance abuse, low intellectual ability or antisocial personality disorder with a lack of empathy. In most cases, it is a combination of several problems that causes a person to end up with us. We administer treatment or help and support for anyone with these conditions", he says.

According to the quality registry Rättspsyk, 86 percent of the forensic psychiatry patients received some type of anti-psychotic drug in 2022. Most often, the less common anti-psychotic drugs are used - the ones that are listed at the bottom of the Wise List (the list of drugs that are recommended by Region Stockholm's drug committee for the treatment of common diseases). 

"We enter a stage where the patients have already tried different kinds of treatment which for several reasons have not worked. We therefore administer a more potent treatment in psychiatry, that requires more frequent follow-ups due to the risk of adverse reactions", Hannibal Ölund Alonso explains. 

There are no drugs available for autism. But there is other help available for people who are experiencing serious problems due to such a disability. 

"We can offer social skills training, where you learn basic things such as how to communicate with other people and how to act in different situations. We can offer this as a group treatment where several people with the same problems participate. That way we can act out scenarios where we show what to do in different situations", says Hannibal Ölund Alonso. 

Want to stop using drugs

According to the quality registry, around one out of four patients receive the drug to try an straighten out some form of substance abuse at some point during the care. More people, roughly one in three patients, receive counselling and information about addictive disorders as some point. Even more people, or roughly 85 percent, are asked to take regular drug tests, something that is often a requirement for discharge from outpatient care. 

"However, many people who come to us say as early as the first week that they want to stop using drugs. But so many other things are happening around them. We usually wait until the patients have progressed a bit more in their treatment and their psychotic disorder has stabilised. We then administer different types of treatments against substance abuse, individually designed. Motivating talks is a common treatment", says Hannibal Ölund Alonso. 

Other common secondary diagnoses are different types of personality disorders. It may involve problems to handle emotions that tend to become very strong and shift rapidly. It may also involve a substantial lack of respect for social rules in combination with a lack of empathy. These are people who are looking for quick fixes, easily get stuck in substance abuse and who find it difficult to comprehend consequences of their actions. Psychopathy is a sub-group of personality disorders. 

Behavioural problems as a result of this is treatable, even though it can sometimes be a slow process", says Hannibal Ölund Alonso, who in addition to his position as Chief Physician is also a doctoral student in Katarina Howner's research group at the Department of Clinical Neuroscience, where he conducts research on psychopathic personality traits. 

"Frankly, it's about getting these people to understand how their own actions affect them. If they, for example, want to complete their treatment they need to accept the treatment and cooperate with the staff. It's about getting them to create long-term goals for things that they long for in their own lives. 

Regarding the intellectual level of function there is a broad span within the group, where some people have a good ability and some are perhaps university graduates. It's puts them at a good position where it might be possible for them to enter the workforce after they have completed their treatment. 

However, that is rare. 

On the contrary, many people have an intellectual level that has created obstacles for them in life - especially in school. 

"We have a high percentage of patients with a low level of education and substantial reading and writing difficulties. Many of them have not completed primary school. Those people may have a hard time understanding and relating to information. We need to keep that in mind when we are implementing treatment actions that are based on conversations and reasoning", Hannibal Ölund Alonso explains. 

A court decides when the care should stop

Forensic psychiatric care can be imposed with or without special discharge review, so called SUP. With SUP is the most common. In a case like this, an administrative court will make a decision on ground privileges and leave, and when the care should proceed to outpatient care or stop. 

According to the law, the case should be completed when a number of criteria have been met. One criterion involves the severe mental disturbance that formed the basis of the judgment no longer entailing a risk of repeat offences. Another criterion is about the patient's other personal conditions. 

The first criterion applies to the patient's basic illness in practice, which is in many cases a psychotic disorder. It must be well medicated and stable. 

The other criterion is more difficult to pinpoint - and often more difficult to help the patient with. However, the person needs to be able to take care of themselves and be able to manage chronic disorders, if there are any. 

It may involve managing daily routines, such as sleep, food and rest - factors that are important in keeping a psychotic disorder in check. It may also involve taking control of a previous substance abuse. Or having a place to live, an occupation and an organised financial situation, a functioning day to day life to fall into. Otherwise the risk of a relapse in the disorder increases - as well as a relapse into crime. 

Need support to function in daily life

There are a lot of things that need to be in place here. In many cases, the patient needs different types of support in terms of housing and occupation, something that sets requirements on the municipalities. Sometimes the healthcare sector finds that a patient is ready for a life without care, but the municipality where the patient is a resident is slow in in responding. And the lack of a place to live and an occupation may affect the court's decision. 

At the same time, the patients must show that they can manage their day to day life. A key word here is ability to function. Nurse Malin Källman, who has been working in forensic psychiatry for twelve years, is preparing a doctoral thesis on the ability to function in this patient group. 

Regular assessment ensures the quality of care

WHODAS can basically be used by everyone, regardless of diagnosis, and describes how well you have been functioning for the last 30 days. The instrument has previously been used in several areas, such as stroke care and pregnancy. The assessment is done on repeated occasions as a way of capturing changes. 

"The idea is that a regular assessment should be able to ensure the quality of the care that we are providing. We need to know, for each patient, where the greatest problems lie. And then we need to follow up, for each and every patient, to make sure that the treatment efforts are resulting in measurable changes", says Malin Källman. 

She describes patiens who oversleep when it comes time to take their morning medication, skips breakfast, skips a walk before lunch, eats three portions for lunch and fails to perform their afternoon activity. She also describes staff who wakes the patient who needs to take their medication, motivates patients into eating breakfast, explains what a walk means to their health and shows them how large a suitable portion should be. 

"It's a constant balancing act. We should support the patients so that they reach an independence. But we need to find a level where they are not stressed out by requirements that are too high, while they should also not live in misery", says Malin Källman. 

In one of her studies, the patients have assessed themselves in parallel to the staff assessing their abilities, in both cases using the WHODAS questionnaire. This study has not yet been published, but it is already obvious that the assessments differ - with the patients thinking that their ability to function is better than what the staff thinks. In an upcoming study, the researchers will examine how the patients think when they are answering the questionnaire, everything in an attempt to understand what might be causing the discrepancies. That study has not yet been completed, although you could imagine several explanations". says Malin Källman. 

"Some patients might think back to how they once used to function, before the got sick. Others might answer based on a reality that they are accustomed to. A person who has grown up in a home with alcoholic parents or who has lived on the street might have another frame of reference in terms of when a room can be considered cleaned, for example. 

Two out of three report improvements

During 2022, forensic psychiatric care ended for 155 patients, according to the quality registry RättspsyK, which includes 85 percent of the patient group. In the latest annual report, estimates of life quality was reported for roughly one thousand patients who had completed their care at some point in 2009 and ahead. For each patient, previous estimates were compared to later ones. This provides a basis for describing how many patients feel that their life quality has improved, deteriorated or remained unchanged after they have received forensic psychiatry care. Two out of three report improvements. In other words, an increase in life quality - after years of deprivation of liberty and involuntary psychiatric care. 

However, this figure only included patients who have completed their care. And in order to do that, a patient must have control of their medications, daily routines, living arrangements and financial situation. Helping the patient gain control of these basic elements of day to day life is key factor in forensic psychiatric care. 

Forensic psychiatrist Hannibal Ölund Alonso explains what can happen in an administrative court when a person completes their forensic psychiatric care. 

"I was there as late as last week with a former patient. She told me and the court that she was grateful for the care that she had received and she described what it had meant for her. She has gone from being terribly tortured as a result of her illness and missing people around her to now having a life that she is satisfied with. We often hear this. We get to be there when these severely ill people finally feel that their life has content and meaning.