Abstract
Some international jurisdictions route individuals for whom criminal responsibility is foreclosed because of mental disorder from the penal system into a forensic psychiatry regime. Such rerouting might be presumed preferable for such individuals, because it is intended to offer a humane alternative to incarceration and is often viewed by the public as an avenue for accused individuals to avoid accountability. Our clinical experience corroborates European findings that at least some individuals who have been placed into forensic psychiatric care would have preferred to remain in the penal system. We report on our preliminary qualitative investigation into the reasons why some forensic psychiatric inpatients in the Canadian province of Ontario would prefer to be incarcerated. Using a grounded theory methodology, we identify six thematic categories of reasons for this preference. Drawing on these themes, we propose that participants perceive inpatient forensic psychiatric detention as posing a greater threat to personal identity than incarceration as well as feel despair associated with the perceived futility of resisting identity-shaping pressures in this environment. Participants’ concerns re-emphasize the clinical challenge, but also the importance, of providers’, supporting patients to associate hope rather than harm with the aim of personal transformation through inpatient forensic psychiatric care.
- despair
- forensic hospital psychiatry
- international forensic psychiatry
- patient perspectives on detention
In some international jurisdictions, individuals who are found to have carried out criminal acts while their will is overborne by mental illness are routed from the penal system to a forensic mental health system.1 In Canada, this process is governed by the Criminal Code.2
Although the forensic mental health system is intended as a humane alternative to the penal system,3 it is often perceived in the public imagination as an avenue for accused individuals to avoid accountability.4,–,6 Both views would suggest that detention in a hospital in the forensic mental health system is preferable to detention in jail. Our clinical experience corroborates European findings that, counterintuitively, at least some individuals detained in hospital as forensic psychiatric patients think incarceration would be preferable.7,–,9 This attitude suggests an incongruity between the perspectives of at least some forensic patients and the intent of forensic mental health systems, which may have important implications for patients’ care and progress.
Existing literature identifying and exploring the preference to be incarcerated among forensic mental health patients is scant. Three Belgian studies shed some light on the possible sources of this preference. To and colleagues observed and interviewed medium- and high-risk mentally ill offenders who were detained in two types of forensic residential settings: treatment settings and correctional settings.7 The four participants detained in correctional settings expressed a preference to be in prison rather than a forensic treatment institution, which they had experienced in the past. These participants reported feeling a greater sense of control and freedom in prison as compared with their experiences in forensic treatment settings. They also reported proportionally more positive than negative experiences compared with participants detained in forensic treatment settings.
The findings of To et al.7 are consistent with those of De Smet et al.,8 who conducted in-depth interviews of older mentally ill offenders. In this work, participants’ reports of their experiences relating to time in prison were proportionately more positive than their experiences in institutional care, which included psychiatric hospitalization among other settings.
Finally, Mertens and Vander Laenen9 found that participants who had been moved into the forensic mental health system after prison sometimes felt more deprived than both those who remained in prison and those who had been moved to general mental health settings. They note that participants in the forensic mental health system “experienced a range of deprivations and sometimes felt even more deprived than those in prison facilities (e.g., with regard to the loss of liberty and autonomy)” (Ref. 9, p 1357).
Although these studies compare detention experiences in forensic mental health settings and correctional settings, their conclusions about if and why some participants might prefer one setting over the other are largely derived indirectly from the evidence. Furthermore, their findings potentially reflect social dynamics and institutional structures particular to the Belgian context. The current project, although preliminary, is a step toward addressing these limitations of the existing literature in that we inquire more directly into forensic mental health patients’ preference for jail in a different jurisdiction: the Canadian province of Ontario.
In Canada, the court determines whether an accused person’s mental disorder foreclosed their criminal responsibility by preventing them from appreciating the nature and quality of their act or knowing that it was wrong.10 The question of whether or not mental disorder negated the criminal responsibility of the accused may be variously raised by the accused, the prosecution, or the court itself, depending on the evidence presented.11,–,13 If the court finds, on a balance of probabilities, that this decidedly high bar is met, the person is found “not criminally responsible on account of mental disorder” (NCR).14
The NCR verdict, which routes the accused from the penal system to the ambit of the provincial review board (the review board), is neither a conviction nor an acquittal; it is a special verdict that aims to protect society while treating NCR persons fairly and providing them with opportunities to receive treatment. Persons found NCR will remain under the jurisdiction of the review board until the review board finds that they do not pose a significant threat to the safety of the public, at which point they are granted an absolute discharge.15
Although the review board must review each NCR person’s disposition on at least an annual basis15 to ensure that the disposition is the least “onerous” and least restrictive possible, there is no timeline whereby an absolute discharge must be granted. In fact, a person may remain under the jurisdiction of the review board for life. Similarly, there is no timeline by which persons found NCR may be assured of community living privileges while they remain under the review board. In fashioning a disposition, the review board must consider, primarily, the safety of the public, as well as the mental condition of persons found NCR, their reintegration into society, and their other needs.16 For as long as the review board deems it necessary, the NCR person will be detained in hospital.
The indeterminate duration of the review board’s authority over an individual is recognized to be just one of the controversial features of the provincial review board system in Canada, which has “been the subject of vigorous political debate” (Ref. 17, p 174). Although indeterminate time spent under the jurisdiction of the review board has been found by the Supreme Court of Canada to be constitutionally sound,18,–,20 some NCR individuals experience the indeterminacy of their supervision as punitive and disproportionate.21
Criminal lawyers in Canada sometimes counsel their clients against seeking to have their mental health considered as part of their defense3,17 because, depending on the offense, detention duration is likely to be considerably less in the penal system, where most sentences are typically of a fixed duration. A 2006 nationwide study found that 60 percent of NCR individuals remained under the review board after five years, and nearly 25 percent of individuals remained under the remit of the review board 10 years after their offense.3 Compared with the review boards in the other two most populous provinces,22 the Ontario Review Board has more recently been found to have the highest proportion of individuals found NCR remaining under the review board and remaining detained in hospital after five years.23 The proportion of individuals achieving absolute discharge at five years in Ontario is increasing,24 however, so it is unclear whether the length or indeterminacy of detention, or other factors, are motivating some forensic patients to prefer incarceration. The current research is designed to begin to shed light on this question.
Methods
To understand the perspectives of forensic psychiatry inpatients who expressed a preference for being in jail, we undertook a small-scale qualitative investigation informed by grounded theory methodology and using semistructured interviews as our data collection method.
Grounded theory methodology is well suited for projects that involve a lack of existing literature and participants from marginalized groups.25 Line-by-line inductive coding allows analytic categories to arise out of the data as opposed to being determined in advance.26 This frees researchers from relying on existing theoretical constructs, which is important when there is little literature to draw on.25 Coding line by line also promotes focus on participants’ subjective experiences, which is important when dominant narratives may be poor reflections of marginalized experiences.26,–,28
Interviews were conducted at a locked forensic psychiatric program in a hospital in Ontario, Canada, which we agreed not to identify. Research ethics approval was sought from the hospital’s Research Ethics Board (REB), which operates in accordance with the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans.29 Given the known concerns about research in forensic psychiatry settings,30 special attention was paid to maximizing voluntariness, protecting confidentiality, and supporting participants’ emotional well being.
The research team recruited only individuals detained in hospital under the Ontario Review Board after having been found not criminally responsible. Because this project is preliminary in nature, it was appropriate for us to adopt a convenience sampling approach. To be eligible to participate, participants had to hold the preference for being in jail as opposed to being detained in their forensic psychiatric setting, as well as be English-speaking, capable of deciding to participate in research (which was determined in collaboration with the health care team), and willing to have a conversation about their preference.
Recruitment was led by research assistants employed by the hospital’s research institute who operate at arm’s length from the clinical team. With consent, clinicians could refer patients to the research assistants. Alternatively, patients could self-refer based on information about the project provided on their unit.
The 11 individuals who participated in this study represent a small fraction of forensic patients detained at the study site. For context, as of 2021, there were 885 forensic psychiatry inpatient beds in Ontario with individual facilities having between 20 and 200 beds.31
All study participants were male. All participants were diagnosed with a psychotic disorder, ranging from schizophrenia, schizoaffective disorder, and delusional disorder to unspecified schizophrenia spectrum disorders. Eight participants had a co-occurring substance use disorder, whereas two had documented co-occurring personality disorders. Nine participants had index offenses that involved violence, such as assault with a weapon, aggravated assault, assault causing bodily harm, and robbery. Based on these characteristics, the sample has notable similarities to Ontario’s broader forensic mental health population. In recent analyses, psychotic disorders were found to be the most common diagnoses,24,32 with a high frequency of co-occurring substance use disorder (57.2%), less frequent co-occurring personality disorders (27.8%), and a high proportion of violent index offenses (69.9%).32 Each participant had experienced jail in some way, either by having previously served a term of imprisonment or through detention pending trial. Eight participants had experiences of seclusion during their forensic psychiatric detention.
Based on patient records, participants’ admissions ranged from under a year to four years in duration, with an average length of approximately two years. Participants’ time under the remit of the review board, however, better reflected participant narratives describing much longer interactions with Ontario’s forensic psychiatric system. Time under the review board ranged from less than a year to over 20 years. Six participants had been under the review board for less than three years, whereas the remainder had been under the review board for 10 years or more. This mismatch between admission lengths and time spent under the review board can be explained by changes in participant disposition over time. Participants may have been admitted to other inpatient forensic psychiatry facilities (to access specialized services or different levels of security) or may have had periods of community living while still under the jurisdiction of the review board.
Semistructured interviews were conducted in meeting rooms in clinical areas. The interviews began with a review of the informed consent form. The interviewer offered participants the opportunity to review the form independently if they preferred.
The interviewer asked participants the interview questions and encouraged them to expand upon their answers through clarifying follow-up questions (see Table 1).
Interview Questions
Interviews were audio-recorded. A research assistant transcribed the interviews and removed identifying information. Deidentified transcripts were subjected to two rounds of coding by the authors. Through discussion after having independently coded the transcripts line by line, we established seven refined codes that we believed reflected the central themes of the interviews. We applied these codes in the second round of coding. Although our use of the codes was highly consistent, deviations and evolving understanding of our codes have been managed through ongoing discussion.
Results
In keeping with our qualitative methodology, the number of participants who endorsed specific themes will not be presented. Instead, we have adapted the approach of Shepherd and colleagues for implying quantity to our project.33 We will use “small minority” when an idea was endorsed by three or fewer participants, “minority” when four or five participants endorsed an idea, “majority” when six to eight participants endorsed an idea, and “large majority” when nine or more participants endorsed an idea.
As reflected in Table 2, rather than engaging in a wholesale glorification of jail, some participants described ways in which being in a forensic mental health setting can be roughly similar to being in jail or can be better in certain respects. A minority of participants identified similarities between the settings. A small minority described ways in which the forensic psychiatric setting can be better than jail, such as by having less violence and offering better day-to-day quality of life.
Participants’ Tempering Perspectives on the Relative Merits of Being in a Locked Forensic Psychiatry Program in a Hospital Rather Than in Jail
Despite these tempering perspectives, all participants ultimately believed that, for them, being in jail would be preferable to forensic psychiatric inpatient detention. As the foregoing discussion of the provincial review board system would have suggested, a majority of participants expressed a belief that a jail sentence would be, or would have been, shorter than forensic psychiatric detention.
We identified an additional six thematic reasons for preferring incarceration in participants’ responses: desire for clarity, motivation, social disconnection, being misunderstood, institutionalization, and masculinity. Each theme will be discussed in turn in the following subsections.
Desire for Clarity
A large majority of participants gave reasons for preferring incarceration that related to a perceived lack of clarity in the forensic psychiatric context (see Table 3).
Participant Statements Describing Areas Lacking Clarity in the Forensic Psychiatry Setting
A majority of participants identified the indeterminate duration of their detention as a factor that made forensic psychiatry less preferable than incarceration. One participant described a seemingly endless loop in inpatient forensic psychiatric detention, stating “tomorrow is the beginning of being here again.” Conversely, others noted that knowing one’s release date, as they would in jail, would be a source of comfort or motivation.
Participants also described uncertainty related to authority and protocol. This took two forms, each endorsed by a minority of participants. One view was that forensic psychiatry settings lack defined structure in terms of expectations for behavior, rules, and responsibilities. Participants contrasted this with the strongly enforced structures of rules and authority in correctional settings. The other view was that rules and authority structures in the forensic psychiatry setting are byzantine or not reliably enforced.
Motivation
Closely associated with the previous theme, a small minority of participants described the lack of clarity in forensic psychiatric settings as affecting patients’ motivation. They believed jail is preferable to a forensic psychiatric setting because it offers a structured, rule-based, and consequence-heavy environment that is more conducive to motivating desirable behavior (see Table 4).
Participant Statements on Impediments to Motivation within the Forensic Psychiatric Setting
Correspondingly, this small minority of participants described the relatively permissive structure of the forensic mental health setting as allowing for, or even fostering, languishing. One participant shared his observations about the impact of a lack of enforced rules, such as rules related to hygiene. He described other patients as having undergone a form of personal capitulation. He concluded by saying,it becomes a situation where it’s that they get so deeply into that realm of just not caring, which is not caring about themself, where they lose themselves tremendously. And then to the point where it’s like they become needy. You know what I mean? And they become dependent. They become entitled. They think that everything needs to be given to them just because they’re in a system like this.
One participant commented that lack of motivation can bleed into life postrelease from a forensic psychiatric setting:After you come out of one of these places you tend to be a bit, ah, like sort of down on yourself. Like, oh, I’m schizophrenic, I’m just going to live off [a disability support program]. You know? Take it easy. Not get caught. Not get in trouble with the law. ‘I don’t want to go back’ becomes your whole focus, instead of forging ahead.
Social Disconnection
A minority of participants expressed that detention as an inpatient in a forensic psychiatric setting, as opposed to having been sentenced to a term of imprisonment, more profoundly impaired their social opportunities. A minority of participants spoke to the idea of social disconnection in a way that focused on interactions with peers while detained in hospital, whereas a small minority described barriers to connecting with the larger community because of detention within the forensic psychiatric system (see Table 5).
Participant Statements About How the Forensic Psychiatry System Impairs Social Connection to a Greater Extent Than the Carceral System
With respect to impoverished social opportunities within the forensic psychiatric setting, participants made two distinct observations. A small minority of participants felt there were simply fewer opportunities to interact with peers in their forensic setting compared with carceral settings. The quality of the interactions with peers in their forensic psychiatric setting was also discussed by a small minority of participants. Participants making observations in this vein indicated they perceived their copatients, who represented the majority of interpersonal contact available to them, as having more severe mental illness than themselves. This contributed to why they found interactions with other patients unfulfilling, if not detrimental, to their mental health and motivation.
A small minority of participants took their analysis of the effect of admission to forensic psychiatry on social connection to a still deeper level. One discussed the effects that repeated admissions had on their relationships with friends and family, saying, “And I’m really trying to get back out there and put forth that effort to be there for them whenever they need me. And the system is basically barring me from reaching that potential.” Another participant shared his sense that a forensic mental health detention is a greater barrier to future social reintegration (i.e., postrelease) because of the different assumptions that accompany forensic psychiatric and jail experiences. Surviving jail might demonstrate resilience to certain employers in certain industries, whereas detention in a forensic hospital inspires only fear and mistrust.
Although incarceration would certainly also result in separation from family and other loved ones, participants outlined how the uncertainty of the term of detention in forensic psychiatry creates an indefinite rupture that is more psychologically burdensome.
Being Misunderstood
A commonly endorsed theme, which was raised by a majority of participants, was the perception that either being detained in the forensic unit, or treatment in these settings, reflected a miscarriage of justice or an inappropriate pathologizing of participants’ actions or mental life. It is possible to interpret participants’ perspectives, such as those reflected in Table 6, as erroneous or as features of participants’ mental illness. These comments remain significant, however, because they speak to participants’ understandings of their situation, which should be expected to affect the way they experience forensic psychiatric detention.
Participant Statements About How They Feel Misunderstood in the Forensic Psychiatry Setting
A minority of participants viewed their detention as resulting from a miscarriage of justice, citing various elements of their legal proceedings that they believed had been mishandled. Although participants referred to real legal concepts, we were unable to assess how these applied in participants’ circumstances.
A minority of participants contended that the forensic system had inaccurately assessed their mental state. This had various consequences, including misdiagnosis, excessive interventions, and inappropriate characterization of their religious practices and beliefs as symptoms of mental illness. These participants offered alternate explanations for their condition, such as contending that their beliefs and behaviors are within the normal range of human experience. A final small minority of patients contended that their providers underestimated their abilities and denied needing the support of a hospital environment.
Without these perceived mischaracterizations, participants believed they would have been sent to jail or perhaps would not have been detained at all. Participants who put forward ideas associated with this theme were generally in agreement that jail would be a more appropriate setting for them than a forensic psychiatric unit. Some participants also believed that their religious practices would be more tolerated, or not as actively misunderstood, in carceral environments.
Institutionalization
A majority of participants put forward ideas related to a loss of self to the institution that, through its structure and bureaucracy, they perceived to work against progress or successful exit. This theme can be detected in the quotations featured in Table 7, as well as quotations that have appeared in previous sections. Collectively, participants’ comments offered a multidimensional account of the ways a forensic mental health admission wore on participants’ sense of self and pushed them, either intentionally or unintentionally, toward loosening their personal identity.
Participant Statements on Greater Institutionalization in the Forensic Psychiatry System
A small minority of participants spoke about the constant surveillance within the forensic setting and pointed to the pressure they were under to conform to institutional expectations at the risk of continued loss of freedom if they failed. One participant expressed how learning the system and playing its game were prerequisites to release:Essentially, because there’s no set time for the charges I have. It could be five years, or it could be 20 years, depending on my ability to understand what the charges are, and make way into better understanding of how to understand the system, and how to get out of it. So, taking your meds. Talk to your doctor. Doing vocational work. Essentially all that.
A small minority of participants described difficulty in maintaining good physical health in the face of prolonged admission and the side effects of antipsychotic medication. These observations compound the concerns participants shared about motivation and mental health, described above.
Participants’ comments indicated that, in their assessment, prison was not nearly as invasive, controlling, or erosive. Jail, paradoxically, was perceived as allowing for greater freedom, both in terms of allowing those detained to eventually leave but also in terms of daily life: “It really sums up to one thing: freedom, and being able to do what you want, to a bigger extent.” As described in the section above on “Being Misunderstood,” this attitude was also seen in participants’ comments related to religious practices.
Masculinity
A small minority of participants described detention in a forensic mental health setting as having implications for their gender identity and sexuality that differed from what they experienced in a carceral environment (see Table 8). This small group of participants spoke about this idea in several different ways.
Participant Statements on the Greater Affront to Masculinity within the Forensic Psychiatric Setting
One participant contended that time in jail would enhance one’s masculine identity through its association with pride and toughness. By contrast, time spent as a forensic psychiatric patient erodes masculinity, in his view, through its association with fear and weakness (“you didn’t be a man”).
One participant discussed how forensic admission impeded the performance of gendered roles or disrupted important relationships with other men. This participant expressed a strong desire to be in jail rather than detained in hospital, as jail was where his “fatherhood” was; he felt as though going to prison would be consistent with his forefathers’ experiences and knowledge. By contrast, being in a forensic mental health setting disconnected him from male relatives in the prison system and the mentorship that they could provide him.
A third participant perceived his sexuality to be constrained and scrutinized in the forensic psychiatry environment. In this most physical articulation of the way masculinity is affronted within the forensic system, this participant expressed his belief that he is surrounded by people who find his sexual desire aberrant and who want to constrain his libido through medications and modification of his genitalia.
A final, but perhaps more tenuous, way in which the theme of masculinity presented in a small minority of participants’ comments was their greater familiarity with, and ability to relate to, the physical form of authority encountered in jail. This form of authority is arguably more associated with masculine socialization. One participant explicitly linked his responsiveness toward this style of authority to experiences with his father, noting that “the gun, the billy club, that real old school kind of beat-you-up kind of mentality is what I grew up with, with my dad.”
Despair
Although it arguably does not speak directly to the reason why some forensic mental health patients would prefer incarceration over a forensic mental health admission, we would be remiss not to draw attention to a further important theme that emerged in a majority of participants’ comments: feelings of despair, hopelessness, helplessness, or abandonment in connection with their admission. These feelings seemed to be the affective side of the themes reviewed above. As evidenced in Table 9, and elsewhere, a sense of deep hopelessness was palpable in participants’ remarks.
Participant Statements Reflecting the Sense of Despair They Experience in the Forensic Psychiatric Setting
Discussion
Although this is admittedly a preliminary investigation conducted with a small convenience sample of forensic psychiatry inpatients, it provides a basis to support drawing connections between participants’ preference for jail and existing evidence from forensic psychiatry and adjacent disciplines. We expected participants would prefer to be in jail because of the likelihood that a jail term would be of shorter duration than their forensic psychiatric hospital detention and their entanglement with the provincial review board more generally. Certainly, participants in the present inquiry expressed this view. But participants conveyed a still more complex picture of what motivates them to prefer incarceration. Even the concerns associated with the time spent in forensic psychiatric detention were more nuanced than we anticipated. Participants drew attention to how uncertainty around the duration of their detention as forensic psychiatric inpatients was an added source of distress that they saw as more prevalent in the forensic system. That uncertainty around the length or conditions of detention can cause stress among those detained is not an unprecedented finding. A similar phenomenon has been noted in research about imprisonment, as aptly summarized by Crewe.34
Further, our study supports and elucidates the observation by Mertens and Vander Laenen that participants in psychiatric treatment facilities experience them as “total institutions” as described by Erving Goffman.9 For Goffman, total institutions, including psychiatric hospitals, are characterized by a separation from the broader society, a social classification of “staff” and “inmates” (those who are detained), and great insularity.35
Although Goffman’s description of the social life and the plight of the patient in a psychiatric hospital, based on his 1950s observational study, has been criticized for painting an overly dismal and uncharitable picture of life in psychiatric facilities,36 we agree with Mertens and Vander Laenen that his insights are useful points of departure for understanding our participants’ experiences.
Many comments from participants in the present inquiry were consonant with Goffman’s sociological analysis of institutions. This was perhaps most evident in comments associated with the theme of institutionalization. This theme corresponds closely with Goffman’s idea of “mortification of the self” whereby the total institution aims to dismantle the self of the incoming “inmate” and refashion it through the exertion of unrelenting social forces from which the subject cannot retreat.35
Sociological theorizing and empirical investigation have associated similar kinds of deleterious effects on individuals’ sense of identity with institutionalization generally35 as well as with imprisonment.37,38 The current investigation provides further evidence that some individuals in forensic psychiatric detention share similar experiences. Participants identified that disruption of social relations impaired their ability to be connected to their community and to perform social roles and obligations. They understood that narratives would be attached to them that may not be consistent with their self-perception or the way they wanted to be seen. For instance, they worried about the way in which their masculinity is, or would be, undermined. And participants felt keenly that the way in which their forensic setting operated, both intentionally and unintentionally, disrupted their sense of self.
With the tentativeness appropriate to the early stage of research on this topic, we theorize a connection between uncertainty, disruption of sense of self, and the despair that was described by a majority of participants. Although participants did not view either prison terms or forensic psychiatric detentions in hospital as desirable, they seemed to view forensic psychiatric settings as presenting greater threats to personal identity. Threats to personal identity that participants thought were characteristic of the forensic psychiatry environment included erosion of motivation, social bonds, physical health, and masculinity. Frequently longer, and indeterminate, detention gives these forces more potential to disrupt participants’ sense of self in forensic psychiatry as compared with incarceration.
Personal narratives related to misdiagnosis, miscarriage of justice, and resourcefulness seemed to have a role in how participants resisted what they perceived to be threats to their identities. These narratives contain the idea that the participant does not belong in the forensic system.
We would propose, however, that overall participants sensed themselves to have limited power to resist the identity-shaping forces in, or to control the duration of, their forensic psychiatric detention, contributing to their feelings of hopelessness, powerlessness, and despair.
Of course, one cannot generalize from these participants’ experiences to the experience of all forensic psychiatric patients. Some patients may not be able to engage in this level of reflection because they are simply too unwell. Others may experience the pressure to change in a more positive way or may come to do so with time as they gain coping skills and insight.39,–,41
Indeed, different stages of forensic psychiatric admission have been proposed.39,40 Recent work by Pollak and Palmstierna uses three years as a cutoff for distinguishing long-stay patients, so the six participants in the current study who had been under the review board for three years or less may be suspected of still being in a relatively early treatment stage during which greater acuity and less acceptance are normal.39,–,41 The contributions of participants who had been under the remit of the review board for significantly longer are reason not to simply attribute our findings to participants’ early stage of treatment.
Consistent with reports in other literature,41,–,44 most participants in this study, regardless of their time spent in the forensic psychiatry system, endorsed feelings of hopelessness, powerlessness, and abandonment. This finding is notable because hope has been identified as an important component in forensic psychiatric treatment.44,–,46 Participants in this study have provided additional insight into known challenges with promoting hope in forensic psychiatric settings.
For instance, clinical recovery may be more complicated for forensic psychiatric patients for whom this process is contingent on discovering or constructing an identity that is significantly different from the patient’s current or previous self-understanding.42 If clinical recovery is the means by which forensic risk is managed,43 then identity change may be necessary for at least some forensic psychiatric patients. Our participants’ concerns about the preservation of their identities, the associated despair, and their preference for incarceration re-emphasizes the clinical challenge, but also the importance, of providers’ supporting patients to associate hope rather than harm with the aim of personal transformation in inpatient forensic psychiatric care.
Weaknesses and Future Work
We identify two weaknesses related to our data collection method. First, grounded theory best practice involves multiple rounds of iterative data collection. We were able to organize only one round of interviews on a compressed schedule that did not permit iteration between interviews. This may affect the credibility and resonance of our work.26 Second, the framing of the research question as a comparison between a locked forensic psychiatry inpatient setting and “jail” obscures the differences between different carceral settings. Future work may benefit from attending to these distinctions.
There are several more general limitations of this project. Readers may question whether the self-reported experiences of forensic psychiatric patients can be taken at face value, as they may present inaccurate or incomplete accounts because of acute illness, lack of insight, or other factors. We, however, would join Coffey and numerous other researchers who argue that people with mental disorders offer valuable perspectives into their needs and into service quality.7,30,47,48 In our project, what is important is how patients’ perceptions and understanding of their experiences affect their evaluation of the desirability of their inpatient setting relative to jail.
Our project is limited by its inclusion of only one perspective: that of patients with a known preference for incarceration. This limitation is inherent to the preliminary nature of this project, which is among the first attempts to systematically characterize this phenomenon. We believe it was reasonable to begin by approaching the individuals who held the preference of interest, but we also foresee value in seeking perspectives from a variety of stakeholders.
The project has other limitations of a similar nature, which we view as representing exciting opportunities for further investigation. For example, our study was not designed to determine the prevalence of a preference for jail among individuals detained in forensic psychiatric settings, but this would be important to establish in future work. In our small convenience sample, we spoke only to men, whereas participants in the Mertens and Vander Laenen study were all women.9 Further investigation would be beneficial to determine whether a preference for incarceration is equally prevalent among women or held for the same reasons.
Likewise, although the current study was not designed to permit correlating patient characteristics (such as personality disorder diagnosis, length of admission, or experiences of restraint and seclusion) and the likelihood of holding the view that the carceral system is preferable, fully understanding this phenomenon would involve identifying patient attributes that influence their preferences.
Finally, the present research does not begin to address the clinical implications of this preference. We believe this is an extremely important question, especially as it relates to potential effects on patient progress.
Conclusion
The participants of this study shared nuanced, thoughtful reflections on the reasons undergirding their preference to be in jail. Taken together, their narratives suggest that they perceive forensic psychiatric detention as a threat to their identity that they resist to no avail, leading to despair.
In Canada, the forensic psychiatric system aims to protect public safety, to be fair toward people whose mental disorder has foreclosed criminal responsibility, and to provide access to mental health treatment. Our participants’ preference to be detained in a system that aims to punish suggests that not all goals of the forensic mental health system are fulfilled in their lived experiences. We hope that future research will shed light on the kinds of interventions that may help patients who hold the preference for jail experience their forensic psychiatry detention in a way that is more consistent with the aims of the system.
Footnotes
The views expressed in this article do not necessarily reflect the views of the authors’ employers.
Disclosures of financial or other potential conflicts of interest: None.
- © 2025 American Academy of Psychiatry and the Law
References
- 1.↵CrockerAGLivingstonJDLeclairMC. Forensic mental health systems internationally. In RoeschRCookAN, editors. Handbook of Forensic Mental Health Services. New York, NY: Routledge; 2017. p. 3–76
- 2.↵Criminal Code, R.S.C. 1985 (Can.)
- 3.↵LatimerJLawrenceA. The review board systems in Canada: An overview of results from the mentally disordered accused data collection study [Internet]; 2006. Available from: https://www.justice.gc.ca/eng/rp-pr/csj-sjc/jsp-sjp/rr06_1/rr06_1.pdf. Accessed May 14, 2025
- 4.↵HansVP. An analysis of public attitudes toward the insanity defense. Criminology. 1986 May; 24(2):393–414
- 5.↵SkeemJLGoldingSL. Describing jurors’ personal conceptions of insanity and their relationship to case judgments. Psychol Pub Pol’y & L. 2001; 7(3):561–621
- 6.↵MaederEMYamamotoSFenwickKL. Educating Canadian jurors about the not criminally responsible on account of mental disorder defence. Can J Behav Sci Rev Can Sci Comport. 2015; 47(3):226–35
- 7.↵ToWTVanheuleSDe SmetSVandeveldeS. The treatment perspectives of mentally ill offenders in medium- and high-secure forensic settings in Flanders. Int’l J Offender Therapy & Comp Criminology. 2015 Dec; 59(14):1605–22
- 8.↵De SmetSVan HeckeNVertéD. Treatment and control: A qualitative study of older mentally ill offenders’ perceptions on their detention and care trajectory. Int’l J Offender Therapy & Comp Criminology. 2015 Aug; 59(9):964–85
- 9.↵MertensAVander LaenenF. Pains of imprisonment beyond prison walls: Qualitative research with females labelled as not criminally responsible. Int’l J Offender Therapy & Comp Criminology. 2020 Oct; 64(13–14):1343–63
- 10.↵Criminal Code, R.S.C. 1985, c. C-46 (s.16(1-2))
- 11.↵Criminal Code, R.S.C. 1985, c. C-46 (s.672.11(b))
- 12.↵Criminal Code, R.S.C. 1985, c. C-46 (s.672.12(1))
- 13.↵R. v. Swain, [1991] 1 S.C.R. 933 (Can.)
- 14.↵Criminal Code, R.S.C. 1985, c. C-46 (s.672.34)
- 15.↵Criminal Code, R.S.C. 1985, c. C-46 (s.672.81)
- 16.↵Criminal Code, R.S.C. 1985, c. C-46 (s.672.54)
- 17.↵LivingstonJDCrockerAGNichollsTLSetoMC. Forensic mental health tribunals: A qualitative study of participants’ experiences and views. Psychol Pub Pol’y & L. 2016 May; 22(2):173–84
- 18.↵Bese v. British Columbia (Forensic Psychiatric Institute), [1999] 2 S.C.R. 722 (Can.)
- 19.↵Winko v. British Columbia (Forensic Psychiatric Institute), [1999] 2 S.C.R. 625 (Can.)
- 20.↵R. v. LePage, [1999] 2 S.C.R. 744 (Can.)
- 21.↵ShawJDMKingTJKennedyL. Constructing risk through jurisdictional talk: The Ontario Review Board process under Part XX.1 of the Criminal Code. Can J L Soc Rev. 2023; 38(2):180–200
- 22.↵CrockerAGNichollsTLSetoMC. The national trajectory project of individuals found not criminally responsible on account of mental disorder in Canada. Part 1: Context and methods. Can J Psychiatry. 2015 Mar; 60(3):98–105
- 23.↵CrockerAGCharetteYSetoMC. The national trajectory project of individuals found not criminally responsible on account of mental disorder in Canada. Part 3: Trajectories and outcomes through the forensic system. Can J Psychiatry. 2015 Mar; 60(3):117–26
- 24.↵PenneySRSetoMCCrockerAG. Changing characteristics of forensic psychiatric patients in Ontario: A population-based study from 1987 to 2012. Soc Psychiatry Psychiatr Epidemiol. 2019 May; 54(5):627–38
- 25.↵TweedACharmazK. Grounded theory methods for mental health practitioners. In HarperDThompsonAR, editors. Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners. Malden, MA: Wiley-Blackwell; 2012. p. 131–46
- 26.↵CharmazKThornbergR. The pursuit of quality in grounded theory. Qual Res Psychol. 2021; 18(3):305–27
- 27.↵MillsJBonnerAFrancisK. The development of constructivist grounded theory. Int J Qual Methods. 2006 Mar; 5(1):25–35
- 28.↵CharmazK. Grounded theory: Objectivist and constructivist methods. In DenzinNKLincolnYS, editors. Handbook of Qualitative Research, Second Edition. Thousand Oaks, CA: Sage Publications; 2000. p. 509–35
- 29.↵Government of Canada. Tri-council policy statement: Ethical conduct for research involving humans [Internet]; 2022. Available from: https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2022.html. Accessed May 14, 2025
- 30.↵CoffeyM. Researching service user views in forensic mental health: A literature review. J Forensic Psychiatry Psychol. 2006; 17(1):73–107
- 31.↵CochraneDDecusearaO. Forensic mental health in Ontario—A system overview. Presented at: Provincial Human Services & Justice Coordinating Committee Biennial Conference; 2021 Nov 17; virtual. Available from: https://hsjcc.on.ca/forensic-mental-health-in-ontario-a-system-overview-2021-11-17/. Accessed May 14, 2025
- 32.↵ChaimowitzGMouldenHUpfoldC. The Ontario forensic mental health system: A population-based review. Can J Psychiatry. 2022 Jun; 67(6):481–9
- 33.↵ShepherdASandersCShawJ. Seeking to understand lived experiences of personal recovery in personality disorder in community and forensic settings—A qualitative methods investigation. BMC Psychiatry. 2017 Aug; 17(1):282
- 34.↵CreweB. Depth, weight, tightness: Revisiting the pains of imprisonment. Punishm Soc. 2011 Dec; 13(5):509–29
- 35.↵GoffmanE.Asylums: Essays on the Social Situations of Mental Patients and Other Inmates. Oxford, U.K.: Doubleday; 1961
- 36.↵WeinsteinRM. Goffman’s asylums and the total institution model of mental hospitals. Psychiatry Interpers Biol Process. 1994; 57(4):348–67
- 37.↵CohenSTaylorL.Psychological Survival: The Experience of Long-Term Imprisonment. London, U.K.: Penguin; 1972
- 38.↵RoweA. Situating the self in prison research: Power, identity, and epistemology. Qual Inq. 2014; 20(4):404–16
- 39.↵PollakCPalmstiernaT. Reducing risk for future violence from forensic psychiatric patients by using critical factors of the short-term assessment of risk and treatability as a caring tool. J Forensic Nurs. 2024 Apr–Jun; 20(2):95–102
- 40.↵OlssonHStrandSKristiansenL. Reaching a turning point—How patients in forensic care describe trajectories of recovery. Scand J Caring Sci. 2014; 28(3):505–14
- 41.↵ZonanaHNorkoMA. Mandated treatment. In SledgeWrTasmanA, editors. Clinical Challenges in Psychiatry. Arlington, VA: American Psychiatric Association; 1993. p. 249–91
- 42.↵DorkinsEAdsheadG. Working with offenders: Challenges to the recovery agenda. Adv Psychiatr treat. 2011 May; 17(3):178–87
- 43.↵KaliskiSZde ClercqHG. When coercion meets hope: Can forensic psychiatry adopt the recovery model? Afr J Psych. 2012; 15(3):162–6
- 44.↵HillbrandMYoungJL. Instilling hope into forensic treatment: The antidote to despair and desperation. J Am Acad Psychiatry Law. 2008 Mar; 36(1):90–4
- 45.↵MarklundLWahlroosTLooiG-MEGabrielssonS. “I know what I need to recover”: Patients’ experiences and perceptions of forensic psychiatric inpatient care. Int J Ment Health Nurs. 2020 Apr; 29(2):235–43
- 46.↵LuménKLouherantaOKuosmanenL. Forensic psychiatric patients’ experiences of personal recovery: A Wilsonian concept analysis. J Forensic Nurs. 2024 Apr–Jun; 20(2):103–12
- 47.↵LidzCWHogeSKGardnerW. Perceived coercion in mental hospital admission. Pressures and process. Arch Gen Psychiatry. 1995 Dec; 52(12):1034–9
- 48.↵HogeSKLidzCWEisenbergM. Family, clinician, and patient perceptions of coercion in mental hospital admission. A comparative study. Int’l J L & Psychiatry. 1998; 21(2):131–46
