Hope, Risk and Uncertainty: The Management of Madness in English Forensic Psychiatry Hospitals

Forensic psychiatrists are responsible for managing mentally disordered offenders who are deemed to be a risk to themselves and others. At the same time, these doctors are charged with helping their patients to recover, enabling them to leave hospital. The context of perceived risk of reoffending and uncertainties surrounding patients’ potential for recovery create challenges for doctors in these settings. This paper draws on interviews (with 30 psychiatrists and 40 patients), focus groups and hospital site visits to explore these issues. It describes how doctors and patients construct uncertainty and linked to this, emphasise maintaining hope for recovery, as a means of coping with challenges. At the same time, the maintenance of hope has adverse consequences for patients, which creates unease for doctors treating them. The result is that doctors simultaneously espouse the need to maintain hope and pursue actions which suggest that hope for recovery (discharge) has been abandoned. Occasionally they acknowledge that this is the case. These accounts and actions appear to be contradictory and irrational, though they enable doctors to make changes to services to improve patients’ quality of life. In contrast, the accounts of older doctors are more coherent. These doctors appear less inclined to use uncertainty to maintain hope for recovery, but they do emphasise hope. The object of hope is, however, redefined by them in a way which does not include discharge. The paper suggests that the difference between the groups of doctors reflects, in part, socialisation and education processes which differed across generations, particularly with regard to notions of recovery and patient empowerment. The fact that older doctors are much closer to retirement may also explain why these doctors are less engaged in hoping for recovery in the distant future.