The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study

Simpson et al. BMC Psychiatry The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study Alexander I F Simpson 0 1 Stephanie R Penney 0 1 Stephanie Fernane 1 Treena Wilkie 0 1 0 University of Toronto , Toronto , Canada 1 Complex Mental Illness Program, Centre for Addiction and Mental Health , 1001 Queen Street West, Toronto M6J 1H4, ON , Canada Background: Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility. Methods: Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness. Results: Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration. Conclusions: A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients. Absconding; Risk; Forensic mental health; Policies and procedures; Intervention - Background Absconding from forensic institutions presents significant clinical and reputational risks for those institutions, including a heightened perception of risk to public safety as well as a decreased sense of confidence in the efficacy of psychiatric services being provided [1-3]. Yet progressively increasing freedom of movement and community reintegration is a vital part of recovery for forensic service users, tasking the forensic mental health system with balancing the recovery-based and treatment needs of its clients with the larger obligation to protect the public from undue risk of harm [4,5]. Despite the significance and apprehension often associated with absconding events, we know little about how often these events occur. In their systematic review, Bowers and colleagues [6] reported the mean rate of absconding for general psychiatry (excluding forensic services) was 12.6%, calculated dividing the number of absconders by the number of inpatients at the beginning of the study plus those admitted over the course of the study (as per [7]), with a range of 2-44%. Studies from secure forensic hospitals in the U.K. report lower prevalence rates between 1-4% of all admissions [8-11]. Stewart and Bowers [12] reviewed 11 published studies of absconding from forensic facilities, finding a median rate of 0.76 absconding events per month per 100 beds (range 0.04-1.06). Of note, some of these studies are dated and from high security hospitals, not analogous to most modern forensic facilities of medium or minimum security associated with larger hospitals or general mental health units. Recently, we [13] published a casecontrol study of absconding among forensic patients within a large urban psychiatric hospital, finding an overall rate of 14.4% over a 24-month period. Also not well described in the literature are the motivations driving absconding behavior, particularly among forensic patients. Bowers and colleagues [6] summarized the general mental health literature relating to patientreported reasons for absconding. Themes that emerged included a propensity towards impulsive or noncompliant behavior, a sense of treatment failure or disagreement about the need for hospitalization, a widespread sense of boredom and frustration, as well as family problems or a lack of family involvement [6,14]. For others, absconding was reflective of goal-directed behavior, either to complete a task (e.g., related to household responsibilities) or to obtain substances. A recent study of psychiatric patients who absconded in Iran found similar motivational themes, including feelings of boredom as well as missing family members [15]. Few studies have found evidence of symptom-driven motivation when patients are asked directly about their reasons for absconding (e.g., [14]); however, fear and safety concerns were noted to play a significant role in patients decisions to abscond, as were failures in the therapeutic relationship with staff [16]. In forensic samples, patients who absconded endorsed a desire to be at liberty [9], and expressed feelings of frustration related to long periods of detention and a sense that they were not making progress and being allowed greater freedoms [13]. In this latter study, we further found evidence of a group of patients whose absconding appeared primarily motivated by symptoms of illness or behavioral disorganization, as well as a group who absconded mainly or exclusively to complete a specific task, but did not have the required privileges to do so at the time. Assessing risk and designing interventions to reduce absconding in forensic settings Existing literature suggests that certain clinical and risk management issues involved in the care of forensic patients are distinct from general mental health patients [5,13]. All forensic patients are subject to compulsory detention, and many for prolonged periods of time. In addition to problems of serious mental disorder, they commonly also have difficulties of treatment engagement, substance misuse and antisocial behavior. They are overwhelmingly male, of minority ethnicity, and often young. Owing in part to differences in risk and hospital length of stay that distinguish forensic from general mental health patients, the corresponding characteristics of and motivations involved in their (...truncated)