If they’re admitted here because this is a more humane nursing environment, where they’re just going to be able to walk out and about, as opposed to being locked in protective custody and being isolated, then you need to say that, and not say that they’re coming for all this intense therapy which they’re not getting. (Informant 14)
In Canada, a significant proportion of inmates are being diagnosed with chronic mental health problems (Canadian Institute of Health Information [CIHI], 2008) − a trend that only seems to be escalating, as the prevalence of offenders with mental health issues has more than doubled in the past 5 years (Office of the Correctional Investigator [OCI], 2009). The reasons for this increase are two‐fold. First, we have witnessed over the past three decades an increase in the criminalization of persons living with a mental illness (OCI, 2009); and de‐institutionalization combined with poor community resources has led to re‐institutionalization of persons living with a mental illness as prisoners (OCI, 2009, p. 12). Second, the prison environment itself has been linked to the development of mental health problems “as it is characterized, but not limited to, high risk of violence; separation from social support networks; concerns for personal safety; discrimination based on race, religion, sexual orientation or type of offence” (CIHI, 2008, p. 50). In the process, prisons have rapidly become Canada's largest psychiatric facilities (OCI, 2010). Presently, it is estimated that at least one in four new admissions to the federal system is diagnosed with some form of mental illness (OCI, 2011), commonly including the concomitant diagnosis of severe personality disorders (CPHA, 2004). The Canadian Public Health Association (2004) estimates that the lifetime prevalence of psychiatric disorders in men (all diagnoses combined) reached 84.2% among inmates, compared to 40.7% in the general population; thus re‐enforcing the view that the prevalence rate of mental illness in the offender population far exceeds that of the general population. Given an expected growth of the federal prison system by approximately 3,400 inmates by 2013 (OCI, 2011), and that these inmates are equally entitled to healthcare services (including mental health and psychiatric services), increases in nursing care are likely to occur, thus indicating a need to mobilize nurses to treat this population.
Nurses practicing in forensic psychiatry (including the correctional system) are inextricably linked to a complex network of power relations where they must assume functions that seek to maintain social order while performing nursing care. Nursing practice in forensic psychiatry is, therefore, colored by dimensions of a professional practice that go beyond the traditional conception of nursing care. Indeed, Burnard (1992) argues that “the forensic nurse is forced to consider illness, crime, morality, treatment, containment and possibly punishment” (p. 139). Some authors have described the difficulties faced by nurses who work in secure or forensic psychiatric settings (Burrow, 1991a, 1991b; Fisher, 1995; Holmes, 2005; Holmes & Murray, 2011; Jacob, 2012; Jacob & Holmes 2011; Martin, 2003; Martin & Street, 2003; Mason, 2002; Mason & Mercer, 1998, Mason, Richman & Mercer, 2006; Perron & Holmes, 2011; Rae, 1993; Reeder & Meldman, 1991; Rhodes, 2004). Reeder and Meldman (1991) argue that security imperatives and care in these environments are seen as two opposing forces. In effect, nurses who work in secure or forensic psychiatric settings are constantly faced with a contradictory mandate of therapy and custody (Holmes, 2005; Holmes & Federman, 2003; Martin & Street, 2003; Mason, 2002; Peternelj‐Taylor, 1999; Willmott, 1997). This reality cannot be without effects with respect to the delivery of nursing care in these environments.
The objective of this paper is to present the results obtained from a qualitative research study conducted in a forensic psychiatric setting and to explore the dual role associated with being both “agents of care and agents of social control.” Following the narratives provided by nurses working in this field, the analysis that follows will problematize the rhetoric of therapy in forensic psychiatric nursing. In order to support the analysis, this article comprises four sections. The first section will briefly review the study's methodological considerations. Using a combination of Foucault and Goffman's work, the second section provides an empirical contextualization of correctional environments and their effects on nursing care. The third section explains the effects of having a contradictory mandate of care and custody from Festinger's (1957) theory of cognitive dissonance. Lastly, the fourth section provides a critique of disciplinary interventions in forensic psychiatric nursing, as it is explained by the participants.
The objective of the research was to explore the dual role associated with being both “agents of care and agents of social control” in correctional environments where nurses are fully responsible for ward management. Convenience sampling was used as participants were recruited based on their interest in the study. Twenty‐five semi‐structured interviews with nurses were conducted and used as the primary source of data for analysis. Data analysis followed the basic principles of grounded theory (Strauss & Corbin, 1998) as adapted and displayed in a sequential fashion by Paillé (1994) (codification, categorization, integration, conceptualization, and theorization). Codification/categorization procedures occurred as follows: First, the researcher immersed himself in the data by reading interview transcripts trying to explore the possible meaning/significance of the data. This initial step involved repeated reading of the data to nuance initial interpretations. Second, the researcher generated codes based on repeated, line by line readings of the data. The creation of codes was based on the content of each individual statement and its position within the larger contextual/political structure. Initially, these codes were written in the margins of each transcript without following any ranking or sorting structure. Once a few transcripts (3) had been analyzed, codes were aggregated into themes; similar codes were identified and placed together. As the research progressed, themes were re‐evaluated to ensure that they were internally homogenous (combined codes belong together and are coherent) and externally heterogeneous (themes are mutually exclusive). This exercise helped the researcher define how the content of each theme may be articulated both independently and in relation to one another. In order to ensure that the analysis of the data was not concluded pre‐emptively, the researcher analyzed remaining un‐marked transcriptions by using themes as opposed to the codes identified earlier. In doing so, the researcher was able to identify instances in the data that did not necessarily fit the proposed thematic construction. These instances were recognized/accommodated, and served as a foundational element in determining the thematic structure and saturation of the data; thus producing an explanation that remains empirically grounded in the participants’ experiences. As such, the results produced from this analysis will, hopefully, benefit other nurses, in that the empirical data analyzed in this research will find a direct application in the “realities” of nurses practicing in this field (transferability). This analytical process, which included the codification of interviews and gradual categorization and integration of emergent concepts, produced four mutually exclusive categories: (1) the penal apparatus; (2) deviance and representations; (3) the rhetoric of therapy; and (4) the domestic rupture. For this paper, the researcher concentrated on the third category, “the rhetoric of therapy.”
Although one needs to be aware of the threat of imposing pre‐conceived frameworks into the research (Backman & Kyngäs, 1999), it must also be put forth that any conceptualization or theory is value‐laden. That is to say that the end product of the research is a human construction, which is the result of a specific relationship between participants and a particular researcher. Although the resulting conceptualization is the result of a rigorous analytic process, it remains influenced by the researcher's theoretical sensitivity and paradigmatic position (i.e. critical theory).
Given the unique nature of forensic psychiatric settings, there exists particular ethical tensions regarding the care of mentally‐ill offenders (Holmes, 2005; Holmes & Federman, 2003; Mason, 2002). It is conceivable that doing research in such environments remains delicate, since personal, professional, and organizational practices and discourses are subject to scrutiny and criticism. Research, as an invasive look into the realities of those working in forensic psychiatry, could possibly be perceived as a threat to the organization and to prospective research participants (Renzetti & Lee, 1993). In order to ensure the protection of participants, interviews were conducted in private offices and participants were given an alphanumerical code that prevented any form of identification in the dissemination of results.
The correctional environment
Despite being separate entities, correctional and mental health systems have overlapping areas of intervention within the forensic psychiatric setting. Notably, the behavioral management of inmates/patients proves to be one of those areas where therapy and punishment intersect. That is, due to their proximity with inmates/patients, nurses are often asked to participate in the daily management of inmates/patients by deploying disciplinary interventions. Such interventions are deployed by nurses when inmates/patients do not adhere to the units’ behavioral expectations. Using a Foucauldian (1995) interpretation of the disciplinary institution, complemented by Goffman's views on total institutions (1990), this section discusses how the correctional ways of doing influence the manner in which care is conceptualized and exercised in forensic psychiatry, and how the correctional discourse of punishment has infiltrated the therapeutic enterprise of mental healthcare. In this sense, the logic and subtleties of punishment are reconstructed through the rhetoric of therapy and frame nursing practices as an extension of the correctional apparatus.
Enforcing rules—the contradictory mandate
Idealistically the functioning of a forensic psychiatric setting is organized in such a way that therapeutic interactions are emphasized and security interventions minimized for nursing staff. The therapeutic mandate is, therefore, considered to be viable to the extent that nurses are able to engage with inmates/patients and develop a therapeutic relationship with them, while indiscipline is managed by correctional officers. The conceptualization of forensic psychiatric care within many correctional settings works on the assumption that therapy and punishment may be divided and managed by respective professional groups. In practice, however, the nurses’ role within the forensic institution is not completely separated from correctional activities (Holmes, 2005; Holmes & Murray, 2011; Jacob, 2012; Perron, Holmes & Hamonet, 2004). In effect, nurses described how they are expected to be an extension of correctional services by having to enforce correctional rules on the units.
It's two totally opposing forces where you have Corrections who are in a punishing discipline mode, and that's where we have a lot of the difficulties as well because I’m not a disciplinarian, I’m the nurse. [ … ] But that's what we were brought in as. You know, we had to be people who enforce rules. (Informant 1)
In light of the data (as well as existing data from various other research studies), the difficult articulation of therapy and social control makes it possible to draw parallels between the forensic psychiatric setting and what Goffman (1990) and Foucault (1995) respectively call “total institutions” and “disciplinary institutions.” If the works of these authors share certain similarities, both perspectives complement each other, Lagrange (2003) argues, in order to address their respective deficits. Goffman's (1990) analysis of “total institutions’ (referring to institutions that take in charge all aspects of an individual's life) is essential to understand the inner structure and the internal functioning of psychiatric institutions. Foucault's description of the disciplinary institution, on the other hand, harmonizes Goffman's description of internal functioning with the analysis of macro structures and practices, thus positioning the psychiatric institution within a broader strategy of social control (Lagrange, 2003). While Goffman problematizes the internal processes of what he refers to as “total institutions,” Foucault seeks to explore how certain techniques of power, closely linked to social and political structures, are exercised in the management of individuals (Hacking, 2004; Lagrange, 2003). Hence, Foucault's perspective expands on Goffman's original, yet narrow view of the “total institution,” by inscribing it in a governmentality framework.
In his book Discipline and Punish, Foucault (1995) articulates the anatomo‐political dimension of bio‐power (or power over life) by looking at the productive forms of power that seek to generate forces, to make them grow, and to order them (Rabinow, 1984). At the institutional level, mental healthcare professionals, such as nurses, function as agents of the anatomo‐political dimension of power to the extent that they use technologies of “government” in order to manage mentally ill individuals. Within the anatomo‐political dimension of power, technologies of government largely revolve around the use of disciplines to attain therapeutic ends of the institution. Disciplines may be defined as the “methods, which made possible the meticulous control of operations of the body, which assures the constant subjection of its forces and imposed upon them a relation of docility–utility” (Foucault, 1995, p. 137). Foucault's (1995) description of disciplines is useful, here, to explore the dynamics at play within forensic psychiatric settings, as it relates to the experiences shared by research participants for whom the disciplinary/punitive aspects of nursing practice were considered to be at the heart of a socio‐professional incongruence. Constantly enforcing rules on the units was regarded as a barrier to the development of a trusting/therapeutic rapport with inmates/patients and reinforced conceptions as authority figures.
To be therapeutic, you do have to get some kind of a rapport with them but you can’t, because there's absolutely no trust there because you’re always at them. (Informant 2)
In order to be a good therapist and develop a good therapeutic relationship, you can't be nitpicking at little rules and regulations because you’re not going to develop that relationship. They’re going to see you more as an authority figure instead of a nurse. I don't think it benefits us as nurses to be acting as correctional officers in that context. (Informant 3)
Under these conditions, where nurses are vested with a dual mandate of therapy and social control, it becomes increasingly difficult to carry out nursing activities and establish a nursing identity.
Some days, you are a correctional officer in here and you are a nurse because of the type of clients we work with. We have to follow rules first, correctional rules and procedures and enforce them. So it's very difficult being a nurse at the same time. (Informant 2)
The disciplinary role that nurses play within forensic psychiatric settings may in fact reinforce a traditional separation that exists between patients and those involved in their surveillance (Goffman, 1990). In effect, as Goffman (1990) stated, the imposed mandate of care and social control tends to establish “a basic split between a large managed group, conveniently called inmates, and a small supervisory staff” (p. 7). Fundamentally, the difficulty in providing nursing care in forensic psychiatric settings originates from this antagonistic mandate of care and social control, as the effectiveness of social control is considered to be directly proportional to the interpersonal distance that is produced between inmates/patients and those who must enforce it (Rhodes, 2004). Nurses are, therefore, in a difficult position where their implication in the correctional ways of doing hinder the therapeutic alliance, as the institution's underlying function requires the maintenance of a distance with inmates on account of their dangerousness and deviant status (Jacob & Holmes, 2011; Holmes, 2005).
As years of research suggest, nurses working in forensic environments are inclined to redefine the way nursing care is conceptualized and practiced in order to adapt to their work environment (Holmes, 2001, 2002, 2005; Holmes & Federman, 2003; Holmes & Murray, 2011; Holmes, Perron & Guimond, 2007; Jacob, Gagnon & Holmes, 2009; Jacob & Holmes 2011; Mason, 2002, 2006; Mason & Chandley, 1990; Mason, Coyle & Lovell, 2008; Mason, Richman & Mercer, 2006; Perron, Fluet & Holmes, 2005; Perron & Holmes, 2011; Perron, Holmes & Hamonet, 2004; Peternelj‐Taylor, 2004; Timmons, 2010). As a result, nurses “may feel that they, too, are being set a contradictory task, having to coerce inmates into obedience while at the same time giving the impression that humane standards are being maintained and the rational goals of the institution realized” (Goffman, 1990, p. 92).
Understanding care and custody
According to Festinger (1957), the presence of contradictory messages, such as providing care and imposing correctional rules, may provoke cognitive dissonance on the part of nurses. In effect, Festinger (1957) noted that cognitive dissonance occurs when there is a disjunction between what people know, what people believe in and how people act. In general, individuals seek to create coherence between their knowledge, their beliefs and their actions. Therefore, cognitive dissonance can occur when, for example, people are asked to perform certain tasks which are conflicting with their belief or value system. From a psychological standpoint, cognitive dissonance is unpleasant. Individuals experiencing cognitive dissonance are, therefore, intrinsically motivated to decrease the dissonance. In order to decrease cognitive dissonance, affected people may try to reorganize their behaviors in line with their values or reorganize the way they rationalize their behaviors to fit within an acceptable (personal, professional, ethical, et.) cognitive framework (Paicheler, 1997). For nurses working in corrections, decreasing cognitive dissonance may be achieved in two different ways: by reconceptualising the way nurses provide care in order to align disciplinary/punitive interventions within a rational medical framework; and reconceptualising how they view patients to justify punitive interventions within a correctional framework (Holmes & Murray, 2011; Mason, Richman & Mercer, 2006).
Reconceptualising the provision of care according to a therapeutic framework
According to participants, the foundation of forensic psychiatric environments revolves around an expectation of docility from its inmates/patients. That is, inmates/patients are expected to behave and it is on the account of misbehavior that nursing or correctional interventions are deemed necessary.
The expectation is that you will behave and that if you choose not to behave, then there will be a consequence for it. (Informant 4)
In this case, behavior is the variable from which nursing interventions are tailored. Consequently, much of the therapeutic rationale associated with disciplinary interventions is based on the construction of an accountable individual—or at least the process of rendering someone accountable for their behavior. Behaviors are, therefore, conceptualized as the product of rational thought. Disciplinary interventions serve the corrective function of identifying deviant behavior and applying a consequence to induce a sense of accountability on the part of the deviant individual.
If you choose to act in this manner, then you can expect that there will be a consequence to it. (Informant 4)
Behaviors are rationalized here within a deviant framework rather than a medical one. Nurses feel they must act on behaviors that go beyond sickness and include general misbehaviors on the units. In this following example, the participant explains how nurses may be more lenient with someone who is considered to be sick (i.e., an axis I diagnosis) versus someone who has a personality disorder.
They’re still my patients and everything else but I will be more lenient with my schizophrenics, people that are ill. (Informant 16)
In this research, informants explained how they have distanced themselves from conceptions of punishment and reorganized disciplinary interventions within a therapeutic framework. The application of such by nurses rather than correctional officers finds its therapeutic value in: 1) The avoidance of correctional intervention and; 2) The dialogue nurses create with inmates/patients. As the following excerpts demonstrate, the use of seclusion by nurses is presented as having evolved out of their experiences with correctional interventions where nurses had little power over the outcome of disciplinary measures. The development of various types of seclusion applied by nurses originates from a need to avoid correctional intervention and stay within a therapeutic framework—a rationalization that is believed to be beneficial for inmates/patients.
For a while here, it was happening where anything the person did, whatever they did, would end‐up getting locked [ … ]. The vision changed where we were “OK, let's not involve Corrections as much. Let's treat it clinically, you know, seclude the person or give them a time‐out or whatever before we call Corrections. If that works, great. If it doesn’t, well then we’ll have to deal with Corrections.” (Informant 6)
By keeping disciplinary interventions within a therapeutic framework, nurses explained that it enables a space for reflection on behavior that is considered to be at the center of the inmates/patients’ learning experience, and therefore, gives therapeutic meaning to disciplinary actions. The therapeutic connotation associated with this rationale is centered on nurses’ ability to help inmates/patients develop conflict resolution strategies as conflict arises on the units.
In terms of cognitive dissonance, it is clear that nurses attempt to avoid the more punitive connotation associated with disciplinary action by trying to avoid correctional intervention. That is, by rationalizing various types of nursing seclusion as a less punitive (even therapeutic) intervention on a continuum, nurses are in a position to create some form of congruence between their actions and their professional obligations. In effect, there is an attempt to avoid correctional involvement by taking charge of difficult situations and by presenting their own (contextualized) version of punishment – a version that is more subtle as it is inscribed within a therapeutic framework.
We try to get away from the actual [correctional] type situations, we prefer to do medical observations, and often we’ll send [patients] to their rooms for brief time outs so they can regroup their thoughts, think about the situation. (Informant 7)
In this sense, the deployment of nursing seclusion does not have the same meaning as correctional interventions. Involving corrections represents a shift in emphasis from therapy to punishment.
I stress that very much because I don't want to deal with corrections, they don't want to deal with corrections, let's find a solution between us and the treatment team or with the [patients] or whoever else. Whatever the case may be, we try to resolve it. (Informant 16)
I mean, if he has to be in six point restraints because he's a threat to himself or others, well then he has to be, but get him out of that as quickly as possible, whereas Corrections can, you know, put you in for seven days whether you calm down after the first hour or not, depending on their guidelines. (Informant 6)
Reconceptualisation of patients as deviants
The articulation of care and custody proves to be particularly complex for nurses as they also engage in conflicting clinical representations. It is important here to reiterate the incongruence of care and custody for nurses, to understand the cognitive dissonance that they face in practice: “Do I have in front of me a patient suffering from a mental illness, or do I have a manipulative criminal that merits his sentence and everything that it includes?” On the one hand, there is a genuine attempt to view the inmates/patients as human beings and understand the pathological (i.e., medical) underpinnings of their behaviors. On the other hand, there is the clinical complexity of working with individuals who are labeled as social deviants and manipulators. As other research, including the present study, has demonstrated, this continuous questioning is insoluble, since the perception of risk is often omnipresent in forensic psychiatric setting (Jacob, 2011; Jacob & Holmes, 2011; Holmes & Federman, 2003). The medical rationalization (being sick) is juxtaposed to clinical representations of deviance (Mason, Richman & Mercer, 2006). In effect, the negative representation of inmates/patients was described as an important factor in the way nursing care was delivered. In this sense, the label given to an inmate will influence the type of treatment he will receive from nursing staff.
Half the staff didn't like him because he was a difficult, they can't understand why you’re upset “he's just a loser, good thing he's dead, just a piece of shit off the road.” (Informant 8)
I think if you said “He's an inmate,” it affects their care. “He's a loser.” I’ve heard that. “He’ll never amount to anything.[ … ] You know, get rid of him. He's just going to continue.” Well well, you know. It's a strong statement because if you have perceived that, then you’re not going to do anything for that man either, you know. So most definitely. If you think of patient, you know you have more of a compassionate type of, sincere, you know. (Informant 9)
As this next participant explains, a primary evaluation takes place where the inmate/patient's criminal label is identified, followed by his medical condition. This information is then combined to guide clinical interventions.
For example, if I do see one [patient] who will be muscling another [patient], right away I have to go into the back of my mind with the profile on this person. Immediately, that's the first thing I think about. “Is he a pedophile? Is he a rapist? Is he a murderer? Is he a bank robber? What is he? Ok, now I’ve got the picture.”[ … ] The next thing:”What's his medical condition? Is he schizophrenic? Is he borderline? Depression? Anything.” That's the second bell that goes off in my head. Now I have to put the two together in order for me to approach that person. Now “How do I approach that person?[ … ] It's not like when you’re dealing with somebody from surgery. (Informant 10)
The work of Festinger (1957), once again, can help us understand how nurses manage conflicting cognitive representations. He argues that psychological tension related to conflicting cognitive representations have to be evacuated. That is, the individual involved in such a situation will seek to modify representations in order to evacuate the unpleasant feeling associated with cognitive dissonance. In effect, according to Festinger (1957), the modification of representations is much simpler to accomplish than a modification of behaviors. In forensic psychiatric settings such as the one under study, it is much easier to conceptualize the inmate‐patient as a manipulator, a looser, a con artist and align care plans according to these attributes since they “fit” within the much larger custodial discourse of dangerousness and the need to maintain a distance. The labels associated with being a personality disorder, as well as a criminal, are one of the prominent examples given by participants to exemplify the ongoing clinical tensions for nursing staff. One of the key elements described by nurses was the conniving portrayal of individuals under their care. That is, in‐patients were described as having developed a mastery in manipulation which staff needed to be aware of and establish a distance from. Medical representation was often substituted by deviant characteristics and attributes that nurses must take into account in their practice.
It's a slippery slope when you’re working with personality disorders. And the patients that are here are not first time offenders. They’re not like your first teen that had his break and enter so you can have an opportunity to mould them before they …. The people here have correctional files this thick. They’ve been in all kinds of jails and prison systems. They are experts. They are cons. (Informant 14)
In effect, the official label of inmates/patients was often tainted with negative portrayals of dangerousness. The personality disorder/criminal created the necessary mix of attributes for nurses to justify a defensive and distant approach (in general). Inmates/patients are conceptualized as individuals who cannot be trusted and who will most likely be manipulative.
You have to know that they’re going to trick you 5 times out of 10, you have to be prepared for that and know that whether they’re trying to test you or whether they’re trying to get away with something. (Informant 16)
The difference between working in both environments is that in this environment, forensics itself, you have to be cautious of every minute of every day, of the total time that you’re in the facility. (Informant 10)
You have to intervene with caution because you have to remember that you are dealing with criminals with a mental illness on top of that. (Informant 10)
As a result, nurses are constantly in a position of mistrust, trying to find the ulterior motive that prompts behavior.
I always have to think to myself in this type of environment: “Why are they asking me this? What is this leading to? Why are they questioning?” I mean this “is what they want but; what is this down the road going to get to? What is this ultimately going to lead to?” (Informant 11)
The individual and professional benefits of this re‐conceptualization are great to the extent that it is legitimated within the existing correctional discourses of dangerousness. Following the carceral ideology centered on punishment, getting close to the inmate‐patient must be avoided, since it would go against the conduct that one would expect from professionals working with a criminal population. Goffman (1990) would add that there exists a danger for staff who work in these settings, in that inmates have the capacity to generate a companionate response from staff and, possibly empathy. As a result, this may position nurses in a vulnerable position in relation to the human material they are suppose to discipline and mould in order to assure proper rehabilitation. For example, staff who may attempt to get closer to the inmate‐patient run the risk of becoming “stigmaphils” (Goffman, 1990); that is, nurses who wish to engage in a therapeutic alliance with patients who are labeled as deviant/dangerous (rather than being sick) run the risk of being ostracized by their peers. The next participant goes on to explain how socialization by other group members becomes an important variable in the way nurses practice. In this case, a certain type of learning takes place where nurses are encouraged to minimize interactions.
“Just don't even give them the time of day.” I don't find that very therapeutic. But at the same time, I feel peer pressure to comply with the way they’re doing things, because I don't know another way other than getting manipulated and I see myself doing it to myself all the time. Like I want to spend the time with them and help them out. (Informant 12)
They’re personality disorders. The worst thing you can do is sit down and talk to them. You’re just feeding into their illness and there's this stigma that if you spend time with the client, you care too much, you know. And really I still don't know to this day, I don't know what I’m supposed to do. I would like to help them through it but I’ve been there and helped them through it and then turned around and got manipulated too. So what do you do? You get to a point where you just sort of … I personally hide out in the nursing station. I do meds or I do charge so that I don't have to deal with that. (Informant 12)
Spending time with inmates/patients who are considered difficult/manipulative (often including inmates/patients diagnosed with a personality disorder) may, therefore, be unwelcomed on the units and create mixed messages regarding the way therapy is conceptualized and operationalized.
But very few people will take them in a room and talk one on one with them because of this little stigma about spending too much time, or being too caring, or being too friendly. (Informant 12)
If nurses chose to ignore these social constructs, then these individuals may be subjected to criticism from other nurses who do not agree with the approach—mainly making reference to a negative representation of a maternal attitude toward the inmates/patients.
Question: And this is pretty much nurses looking at another nurse and saying “you’re doing this and” … Is it ever being said to each other like “you’re doing this wrong”?
Answer: Oh yes. Everyday. [ … ]“What are you doing? Are you in there breastfeeding or what?[ … ] Joking but not joking. (Informant 12)
A critique of disciplinary interventions
Despite attempts to re‐conceptualize disciplinary interventions as a form of therapy and realign them into a therapeutic framework, their clinical application remained problematic for many nurses. By comparing current practices with other treatment settings, this next informant problematizes nurses’ participation in a pervasive system of micro‐penalties.
The other thing, enforcing of rules. Something else that's really, really new is the fact we have this punishing role that certainly would not be something seen in geriatrics, not at all. And you know what? You can call it lots of things. You can call it “time‐out.” You can call it [correctional seclusion]. Bottom line, it's a punishment. It's like a child who's been told “They have to go to the room and you’re not getting out until I say so.” So that's an entirely different role from geriatrics because that isn't anything that you ever do. (Informant 1)
This participant goes on to explain the application of disciplinary interventions as extra‐ordinary interventions with mixed therapeutic effects. As many other participants did, comparisons to the management of children were the foundation for the way these are conceptualized. Thus re‐inscribing disciplinary interventions within an acceptable social framework (it is normal and acceptable to punish unwanted behaviors to eliminate that behavior). However, disciplinary interventions such as the ones presented in this research, are considered to help manage deviant behaviors on the units but do not necessarily “treat” anything.
You really really try to avoid that. That's a last resort. You don't want to lock them up because I’m not really certain that that's a really, totally therapeutic thing. [ … ] And for some people … I mean I do understand you know [ … ], as it does with some kids, it does work because it keeps the behavior at bay but I think that's where we’re still working. (Informant 1)
The application of the disciplinary interventions, positions nurses within a punitive continuum. As in many, if not all, forensic psychiatric settings, if the unwanted behavior persists over time, other punitive interventions are applied. The use of various types of seclusion to manage unwanted behaviors is further problematized in the sense that it is now being used as therapy. However, as this next participant explains, whether the inmate/patient is secluded under nursing or corrections, the end product is shockingly similar.
Grey area would be the [seclusion]. I mean in nursing, if we lock somebody behind the door, we’re on the other side of the door, right?[ … ] If corrections locks the guy up, you know, you have to be on the other side of the door. If we lock them up, we’re on the other side of the door. So it's whether if it's a correctional [seclusion] or a nursing [seclusion]. (Informant 17)
It's hard for us to just lock someone up just because they’re bad. I mean that's not what we want to do, you know. You can't put them behind a locked door. You’ve removed them from treatment. You’ve removed them from any training or social aspect of his life. (Informant 6)
The logic of using relative liberties as leverage in the management of behavior was further problematized by participants to the extent that they are used to create a conscious distance with patients. When inmates/patients are considered a management problem, the use of seclusion becomes a tangible solution as it creates safe boundaries of practice but most importantly, offers a solution to manage deviant behavior.
I think that if they are not comfortable, they go into the nursing station and so they’re able to get away from the [patients]. If the [patients] are a management problem, they can be locked in their rooms and so in the end, you won't need the same kind of nursing observations. (Informant 14)
As this next excerpt demonstrates, it becomes all too easy to manage behaviors by keeping the separation existent—by keeping difficult patients under seclusion:
Like, if this is your behavior, these are the consequences and this is how you’re re‐integrated. [ … ] The last that we were told by the doctor is “are they going to be disruptive to the therapeutic regime on the floor.”[ … ] To me, all of it is destructive. It depends on the nurse that decides. “Well do you think they’re going to be destructive? Do you not? Let's just leave him in there. It's easier for everybody.” You know? There's no real procedure to go by. (Informant 12)
It is this logic of separation as a justified therapeutic intervention that is closing the gap between therapeutic and correctional ways of doing. In this case, the espoused value of nurses in the development of a therapeutic relationships with inmates/patients, that are idealistically universal and judgment free, loses its significance. Nursing care is provided for those who have earned the privilege to access it—those who have demonstrated good behavior. Nurses engage in the development of the inmates/patients’ moral careers by creating a system of punishment where access to mental health care may become the leverage point.
In keeping with the participants’ accounts, the fusion between care and custody in corrections was described as somewhat problematic. It is an environment where the correctional and health apparatus cross to serve a new social function. This overlap is delicate because of the ambiguous role that it creates for nurses—a role containing some mixture of both correctional and health imperatives. The difficulty associated with the incorporation of correctional imperatives to nursing care revolves around the imposed correctional duties that are implemented often to the detriment of nursing care. The full daily management of inmates/patients is provided by nursing staff and is, therefore, partly aimed at performing custodial tasks. Idealistically, nurses talk about blending both roles. That is, while engaging in technical custodial activities, nurses would be in a unique position to assess and intervene with inmates/patients from a therapeutic standpoint. In reality, research conducted in many forensic psychiatric settings worldwide shows that nursing practice is considered to be downgraded to strict technical work. The value of having nurses manage correctional units is lost to the custodial imperatives imposed by the institution. Nursing process is, in a sense, lost within a managerial framework.
In this research, participants described that the therapeutic expertise has more to do with the humanization of the correctional structure rather than the application of a unique knowledge in the treatment of mentally ill offenders. As such, the introduction of nurses to the correctional system is a key element in the institutions’ attempt to humanize these environments. Correctional imperatives of punishment are, in the process, re‐conceptualized under a language of therapy. The institution of corrections shifts toward and embraces (rhetorically) the caritative attributes associated with nursing care.
The term rhetoric is employed in this paper to expose my (uncontested) understanding of forensic psychiatric settings as places where specific types of therapy are deployed. Since nurses work in correctional environments, they are under the impression that special types of therapy exist. However, the data obtained from years of research in forensic settings indicate that the introduction of mental health nurses in corrections does not necessarily translate directly into the deployment of therapeutic practices. There is a need for researchers and clinicians in the field of forensic psychiatry to distance themselves from the rhetoric of therapy, a discourse that evidently masks some aspects of the nursing “reality.”
J.D. Jacob would like to thank Professor Dave Holmes, University Research Chair in Forensic Nursing at the University of Ottawa, for his invaluable assistance in the revision of the manuscript.
J.D. Jacob would also like to thank the Social Science and Humanities Research Council of Canada for funding.
© 2012 Lippincott Williams & Wilkins, Inc.