Patient Autonomy versus Risk Management: A Case Study of Change in a High Security Forensic Psychiatric Ward

Increased attention to the civil rights of general psychiatric patients has been an issue for over 30 years. Similar processes in forensic settings have been slower, because of safety and security needs. This paper explores the development of patient autonomy, as well as rates of violence and escape incidents, in a Norwegian high-security forensic psychiatric ward over an 18-year period. A historical documentary method was applied using quantitative and qualitative data. Multiple sources were analyzed, including focus group interviews among current and former staff, reviewing of official documents and staff notes, and examination of records of violent incidents and escapes. Several indicators of increased patient autonomy were found. These were paralleled by more dynamic and individualized routines for treatment and managing risk, new laws, and changed staff characteristics over the study period. Violent incidents decreased, and frequency of escape has remained low. We conclude that maintaining security is compatible with increased patient autonomy and a more normalized everyday life in forensic settings. We infer that changes in patient-staff interactions, related to implementation of relational and dynamic security, may have influenced the process toward increased patient autonomy.