Abstract

Introduction

     Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff’s experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden.

Methods

     Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff’s experiences with these guidelines and suggestions for improvement.

Results

     Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff’s attitudes toward SUD. Participants’ reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate.

Conclusions

     Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the “gap” between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients’ insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services.

Introduction

     Substance use disorders (SUD) significantly increase the risk that patients with psychiatric disorders will commit, and recidivate into, violent crimes (Baillargeon et al., 2009; Fazel et al., 2009; Lund et al., 2012). Treatment efficacy, retention, and outcome are worse for patients with SUD and one or more co-occurring mental disorders (henceforth COD; see Substance Abuse and Mental Health Services Administration (SAMHSA), 2020) (Choi et al., 2013). Forensic mental health services (FMHS) have an urgent need to integrate SUD treatment into clinical practice (Eagle et al., 2019; Jaffe et al., 2011; Kelly et al., 2011) Recently, clinical guidelines including SUD assessment and treatment for COD patients were implemented at a high-security FMHS facility in Sweden. The successful implementation of interventions in clinical settings requires sustained efforts from staff and continuous support from management. The purpose of the current study was to describe health care staff’s experiences with the implementation of the SUD-focused clinical guidelines, directly following its launch and one year later.

Conclusion and clinical implications

     The results from this study highlight the value of unifying health care staff’s attitudes toward COD for the sustained implementation of interventions. One year after implementing the SUD-focused clinical guidelines, some of the initial resistance and skepticism regarding SUD had been overcome and the health care staff were starting to see its benefits. But successful implementation efforts take time, and many implementations in clinical settings fail due to low fidelity to sustained efforts (e.g., Drake & Bond, 2010). Without financial and organizational support, improvements following the implementation are likely to degrade. To improve implementation sustainability, the clinic must carefully plan and allocate long-term financial resources. FMHS should provide ongoing supervision and training, streamline documentation, and monitor changes to and the fidelity of the intervention implementation. Clinics should provide recurring education and workshops, where staff can deliberate on ambiguous results and discuss how to give patients feedback together with staff who have more assessment experience.