Forensic High and Intensive Care: Towards contact-based care in a complex psychiatric practice

This dissertation examines the development and implementation of a new care model in Dutch forensic psychiatry called Forensic High and Intensive Care (FHIC). FHIC aims to foster the transition from control-based care to contact-based care in forensic psychiatry. A new care model in acute psychiatry, High and Intensive Care (HIC), serves as an example. By analogy, Forensic High and Intensive Care (FHIC) has been developed for forensic psychiatry. However, the question is how the HIC model can be translated to forensic psychiatry. To gain insight into this, three research questions have been formulated: A. What can be learned from complex situations at HIC wards? B. What are the characteristics of FHIC and how can implementation be measured? C. How can FHIC be implemented? Chapter 2 presents a study of difficult situations in HIC wards to see what can be learned regarding the development of FHIC. At HIC wards, care professionals sometimes encounter difficult situations. Interviews and a focus group were organized with care professionals from HIC wards. Taking into account the situation, and not focusing only on the patient, can be helpful in the detection of (early) signals or even prevent aggression. Chapter 3 describes the development and core elements of FHIC. The model was developed in expert meetings, using the results of scientific research and experiences from practice. The FHIC model consists of various interventions to reduce coercive measures and increase safety by working on the basis of contact. There are five core elements; care ethics, stepped care, the premise that a crisis is relational, safety in contact and peer expertise. Chapter 4 describes a mixed methods study validating the FHIC monitor. The FHIC monitor is a model fidelity scale of the FHIC model. Audits by trained FHIC care professionals provided the basis for the assessment of the measurement properties of the instrument. After revisions and adjustments, the FHIC monitor proved to be a useful tool to measure the implementation of the FHIC model and to support institutions in the implementation process. Chapter 5 presents a study of two Communities of Practices (CoPs), one for HIC and one for FHIC. The CoPs for HIC and FHIC consist of auditors, project leaders and care professionals working with HIC and FHIC, respectively. Based on qualitative research, various lessons were formulated for the development of CoPs and perceived effects were identified. The audits served as an important vehicle to activate the CoPs and stimulated the implementation of HIC and FHIC. Chapter 6 shows that working on the basis of contact can result in moral questions and dilemmas. A specific form of clinical ethics support is moral case deliberation (MCD). The chapter describes a MCD in a forensic psychiatric clinic about the relationship between contact and safety. MCD can also contribute to a change in culture. Chapter 7 concludes with the general discussion and conclusion. The research in this thesis confirms that FHIC is a promising development. Many forensic healthcare institutions are in the process of implementing FHIC and this process contributes to the intended transition to contact-based care. The thesis also shows that the implementation of FHIC is not easy because it requires a transition at the level of culture, structure, and practices within a complex care practice. Three lessons were formulated for initiatives aimed at shifting from control to contact-based care in complex care practices: 1) pay attention to complexity, 2) use reflection for dealing with complexity, and 3) foster collaboration in complex care. For future research it is recommended to gain more insight into the further implementation of FHIC and the effects of FHIC on (perceived) safety.