Victim involvement in forensic psychiatric treatment: opportunities and challenges from a restorative justice perspective

Abstract

Victims have a right to participate in restorative justice practices, also if offenders are detained within forensic mental healthcare. However, the deployment of restorative justice interventions in the context of forensic psychiatry is limited. This study aims to gain more insight in opportunities and challenges regarding victim engagement in forensic psychiatry. To achieve this, a narrative review study and an elite interview study with ten key figures in the field of victim-offender engagement within forensic psychiatry were carried out. Both studies focused on the following three themes: first, the impact of various diagnoses on victim engagement; second, the effects of victim-offender interaction on treatment, and, third, challenges for victim-offender interaction. The main findings are that restorative justice can, in principle, be carried out successfully within a forensic psychiatric context and that no diagnostic category on the part of the offender should be excluded in advance. Furthermore, victim engagement can contribute to the treatment of mentally disordered offenders by increasing awareness, motivation and compliance, improve self-image and uncover areas of concern. Apart from these opportunities, several challenges – such as adequate preparation, correct timing, and expectation management – have to be taken into account for effective restorative justice practices.

Keywords:

• Forensic psychiatry
• restorative justice
• victim-offender interaction
• forensic psychiatric treatment
• resocialization

Introduction

Within the European Union, the importance of victims’ rights is clearly recognized, including the opportunity to participate in a form of restorative justice. Restorative justice has a place in the Victims’ Rights Directive and is operationalized as ‘any process whereby the victim and the offender are enabled, if they freely consent, to participate actively in the resolution of matters arising from the criminal offence through the help of an impartial third party’ (Directive 2012/29/EU). In 2018, in part because of the growing interest in restorative justice and its potential benefits, the Committee of Ministers adopted a recommendation specifically concerning restorative justice in criminal matters (CM/Rec(2018)8), and in the EU Strategy on victims’ rights, the existing ‘lack of knowledge about restorative justice services among professionals and victims’ is problematized (EU Strategy on Victims’ Rights (2020–2025)).

Beyond the EU, restorative justice is also gaining traction. In Canada, the federal government instructed the Minister of Justice and Attorney General to promote restorative justice processes (Department of Justice Canada, 2018). Likewise, the United States shows an increasing restorative justice interest, demonstrated by the growing number of legislative proposals across states (González, 2019). Moreover, very concretely, in the Netherlands, restorative justice is advocated as a starting point in the settlement of, for example, medical errors within private law (Becx et al., 2022; Elbers & Becx, 2020; Laarman, 2023). In short, restorative justice is gaining ground across various countries and legal areas.

However, this growing attention for victims’ rights, including the right to restorative justice, focuses mainly on out of court settlement or negotiations in private law, and the pre-trial investigation and the court hearing in criminal law. The position of the victim in the criminal execution phase has only recently received more attention and the focus has mainly been on the start of the execution of sanctions and its termination and less on the role victims can play during the execution of treatment in forensic mental health facilities (Bosma et al., 2021). In fact, the above-mentioned knowledge gap identified by the Committee of Ministers (EU Strategy on Victims’ Rights (2020–2025)) is even more apparent in forensic psychiatry. A recent review on restorative justice within forensic mental health settings shows that this approach is applied only on a very limited scale, although positive effects on patients and victims have been reported (Martin et al., 2023). Still, much remains unclear about how victims can be properly involved in treatment (Van Denderen et al., 2016).

In general, restorative justice practices are considered to be compatible and to resonate well with the objectives of forensic psychiatry, at least in theory (Daffern et al., 2010; Drennan & Wooldridge, 2014). This compatibility is, at least in part, rooted in the individualized nature of restorative justice practices, tailored to the unique circumstances of each individual to address personal responsibility and help them repair the harm they have inflicted (Bonta & Andrews, 2016). Such an approach is consistent with the responsivity principle of the Risk-Need-Responsivity (RNR) model often applied in forensic healthcare (Andrews & Bonta, 2010; Martin et al., 2023). As such, it is argued that the limited use of restorative justice-interventions in forensic mental healthcare is counter-intuitive as there are evident parallels between the objectives and methods of restorative justice and those of therapeutic functions in forensic care services, such as recovery-based practices and trauma-informed care (Cook et al., 2015; Oudshoorn, 2015).

However, the unique context of forensic mental healthcare also entails certain challenges (Dalhuisen & Bosma, 2021). Restorative justice in a forensic mental health context is special for, at least, three reasons. First, not only the victims are vulnerable but also the offenders are vulnerable due to their mental disorder. In addition, offenders in forensic psychiatry have often been victimized themselves, before or even during treatment (Fritzon et al., 2021; Verstegen et al., 2022). Second, the offender’s behavior may be less predictable, difficult to understand, or (perceived as) threatening – in sum, the disorder may have impact on the contact with a victim. Third, the offender is in a treatment setting, which entails certain responsibilities towards the patient on the part of the treatment team, in particular regarding recovery and resocialization. These factors deserve specific attention in research in forensic psychiatric settings.

To gain more insight in opportunities and challenges regarding victim engagement in forensic psychiatry, we conducted a narrative review and we carried out an elite interview study with ten key figures within the field of victim-offender engagement within a forensic psychiatric setting. The results of both studies are described and discussed thematically below. In our discussion, based on these findings, we formulate some recommendations for forensic practice and further research.

Methods

Narrative review

We conducted a narrative review. To include as many studies as possible, first a preliminary scan of the literature was conducted to identify search terms. Based on this reading the following terms were included to identify relevant literature: Restorative justice, restorative practice, victim offender mediation, forensic mental healthcare, forensic psychiatry, inpatient setting, persons with mental disorders, persons with mental illness, recovery conferences, talking circles. We conducted searches using the following databases: Legal Intelligence, Google Scholar, PubMed and Worldcat. Lastly, studies were identified by manually searching the reference lists of eligible articles (Horsley et al., 2011). We included peer-reviewed scientific studies, published in English, that specifically focus on restorative justice practices with offenders with mental illnesses. The timeline of the search was from January 2000 to August 2023. Initially, the eligibility of studies was assessed by reviewing the titles and abstracts. Subsequently, consensus was reached between the first two authors on which articles were included. Finally, included studies were analyzed by the second author (MK) using a qualitative content analysis approach, with the three focal themes as guiding principles for data collection.

Interviews

We conducted nine semi-structured elite interviews with ten key figures in the field of victim involvement in forensic psychiatry and psychology with which we reached saturation (one duo interview). All participants were from institutions in the Netherlands, and selected based on their specific knowledge and experience. Five participants work as forensic social workers in a forensic mental health hospital who, in their capacity as network facilitators, are also responsible for any potential contacts with victims. The other five participants work for a Dutch mediation agency and were selected for their specific experience in and knowledge of victim-offender interaction within forensic mental health care. One of them had worked as forensic social worker before. Interviews were conducted by the first author (LD) using a pre-prepared topic list and lasted about 1 hour. Afterwards, the interviews were analyzed qualitatively using thematic analysis techniques (Braun & Clarke, 2021; Braun & Clarke, 2006). Permission for this study was obtained from the ethics review committee of the faculty of law of Utrecht University (2021-13) and informed consent has been acquired from each of the participants.

Presentation of findings

To answer the research question, we focused on three themes in our narrative review as well as in the thematic interview analysis (1) impact of various diagnoses on victim engagement, (2) effects of victim-offender interaction on treatment, and (3) specific challenges for victim-offender interaction in forensic psychiatry. In the results sections the results of both the narrative review and the interview study are presented thematically.

Results

We identified eleven studies that met the eligibility criteria, all of which were published between 2014 and 2023. Seven studies originated from the UK (Cook, 2019; Cook et al., 2015; Drennan & Swanepoel, 2022; Dwornik, 2014; Harvey & Drennan, 2021; Tapp et al., 2020; Tapp & Verrinder, 2023;), three from the Netherlands (Dalhuisen & Bosma, 2021; Van Denderen et al., 2020; Van Denderen & Wolf, 2023) and one from Canada (Martin et al., 2023).

Among the eleven peer-reviewed studies, five were interview-based studies (Cook et al., 2015; Dwornik, 2014; Tapp & Verrinder, 2023; Van Denderen et al., 2020; Van Denderen & Wolf, 2023), two were case studies (Cook, 2019; Tapp et al., 2020), one constituted a systematic review paper (Martin et al., 2023), one employed a focused ethnographic approach (Harvey & Drennan, 2021) and two were general research studies (Dalhuisen & Bosma, 2021; Drennan & Swanepoel, 2022).

Impact of psychopathology on victim involvement

Narrative review

All studies describing the influence of mental illnesses on offender participation emphasize that there is not one diagnosis that is, as such, considered to be an exclusion criterium for victim-offender contact (Cook, 2019; Dalhuisen & Bosma, 2021; Dwornik, 2014; Tapp & Verrinder, 2023; Van Denderen et al., 2020; Van Denderen & Wolf, 2023). Two studies show that, as information about formal diagnoses is often unavailable to external restorative justice facilitators, they frequently discern behavior that deviates from the norm and intuitively recognize signs of potential mental health issues (Cook, 2019; Dwornik, 2014), making them more attentive to specific mental health symptoms and offender characteristics rather than to diagnostic labels (Dwornik, 2014).

Several studies have identified specific offender characteristics – which are partially disorder-related – that should be carefully considered when deciding upon establishing contact between victim and offender. These factors include limited problem awareness, reduced empathy, psychological instability, the (in)ability to honor agreements, and the authenticity of motives (Cook, 2019; Dalhuisen & Bosma, 2021; Dwornik, 2014; Tapp et al., 2020; Van Denderen et al., 2020). Limited empathy and limited problem awareness may for example lead to unrealistic expectations of offenders about what can be achieved by meeting the victim. Furthermore, it may give rise to interactions with the victim that come across as insincere, solely transactional, and self-centered, rather than genuinely compassionate toward the victim (Van Denderen et al., 2020). Limited problem awareness and reduced reflective abilities are especially seen in offenders diagnosed with cluster B personality disorders. Beforehand victims must be informed about the possibility of instrumental remorse and the impeded empathy that is present (Dalhuisen & Bosma, 2021).

When not carefully considered, this could lead to secondary victimization (Pemberton et al., 2007). Some concerns are also articulated about the use of substances and the existence of mental conditions where patients have impaired reality testing (Dalhuisen & Bosma, 2021; Dwornik, 2014; Van Denderen & Wolf, 2023). This can for example lead to memory loss about the offense, dishonest behavior such as lying to hide drug abuse, and ambivalence regarding appointments. Offenders with psychotic symptoms may perceive and interpret aspects of the interaction with victims in a profoundly different manner due to hallucinations or delusions – this should be taken into account. For example, a paranoid delusion may undermine basic trust required for meaningful interaction with a victim. In addition, in an acute psychotic state it may be difficult to obtain valid consent. Meanwhile, the presence and influence of psychotic symptoms often vary over time, making the possibility of victim involvement dependent on the mental state of the offender at a specific moment (Dalhuisen & Bosma, 2021). In one interview study a restorative justice facilitator mentioned the ability to communicate and attachment to reality as main factor to determine stability and the ability to participate in the restorative justice process (Dwornik, 2014).

It’s important that the presence of such offender characteristics does not necessarily preclude the success of the restorative process (Drennan & Swanepoel, 2022; Tapp et al., 2020; Van Denderen & Wolf, 2023). Equally important is how potential limitations are addressed in the preparation for and during victim-offender contact. For instance, Van Denderen et al. (2020) explain that even offenders who do not express remorse for their actions may still be capable of answering victims’ questions – which may be valuable for these victims. Furthermore, according to Cook (2019), working with offenders who have severe mental health issues may require different measures, as failure to address these issues properly can significantly reduce the chances of a successful intervention. This is also illustrated in a case study by Tapp et al. (2020) concerning an offender with autism. Drawing from this experience, the authors offer some recommendations for restorative practices involving offenders with autism. These recommendations include: employing clear and simple language, being aware of memory limitations, monitoring for suggestibility, and educating victims about possible social and emotional difficulties. Furthermore, assessing the impact of autism on communication and adapt outcome expectations to foster meaningful interactions effectively.

While offender psychopathology has the potential to negatively impact contact with victims, restorative interventions in forensic psychiatry have also been found to be beneficial for those victims, as these interventions can contribute to the restoration of relations between victims and offenders (Van Denderen et al., 2020), help reduce enduring negative emotions (Cook, 2019; Tapp et al., 2020;), and help gain insight into the offender’s disorder (Van Denderen & Wolf, 2023). Victims were enabled to express their emotions related to the crime, which is found to contribute to their healing and to help reduce their fear of the offender (Van Denderen et al., 2020). The process provides victims an opportunity to obtain a more comprehensive picture of their offender beyond the offence (Van Denderen et al.,2020). This experience can contribute to a shift in the victims’ perception of the offender, from someone who caused harm to someone in need of help (Tapp et al., 2020; Van Denderen & Wolf, 2023). More generally, restorative interventions can also help offenders in their process of safe resocialization, which may, ultimately, be beneficial for victims as well (Dalhuisen & Bosma, 2021).

Thematic interview analysis

In the interviews we conducted, various diagnoses and their possible impact on victim engagement are discussed. Disorders that respondents find most often to be of relevance in this respect are personality disorders, and especially antisocial and narcissistic personality disorders, autism spectrum disorders, psychotic disorders and intellectual disabilities. Subthemes that can be discerned from the interviews are the impact of psychopathology on the process of restorative justice (1), on offenders (2), and on victims (3).

From a restorative justice perspective it is stressed that the type of disorder is not in itself a decisive factor in deciding whether victim involvement is an option. Participants do not exclude certain diagnoses in advance and also consider interaction to be, in principle, possible with all types of diagnoses if the specific characteristics of a case are taken into account. In addition, no clear diagnostic categories where victim involvement is more or less likely could be derived from the interviews; respondents give diverse answers to the question whether they see certain diagnoses more often in the restorative justice process. Still, it appears that the presence or absence of a well-functioning conscience in part determines the extent to which one is concerned with one’s victims and thus able to participate.

At the same time, psychopathology can affect the ability of an offender to participate in and cope with the process of victim involvement. Offenders who struggle with severe psychiatric problems are particularly limited in this respect. Their mental condition may result in a practitioner determining that, in order to protect these vulnerable offenders, mediation or other forms of victim engagement are not an option. Offenders diagnosed with personality disorders are more likely to have the ability to cope with and are more guidable in the restorative justice process. However, regarding this diagnostic category, especially the antisocial and narcissistic personality disorders, a defective conscience and the inability to emphasize with victims tends to be an issue.

To prevent secondary victimization it is paramount to prepare victims for specific characteristics in an offender resulting from their disorder(s) that can become apparent during the interaction. For instance, the fact that an offender may react abnormally to stress, or may show inappropriate emotions (e.g. laughter). Regarding personality disorders and autism spectrum disorders an inability to empathize with others is clearly recognized as a point of interest. With these disorders a challenge in victim-offender contact is the fact that offenders may be self-centered, and ‘the conversation quickly turns back to them’. If this can be communicated to the victim beforehand, the victim can take this into account during the interaction.

Treatment effects

Narrative review

The majority of studies highlight that the restorative justice process effectively serves therapeutic goals related to recovery and risk reduction (Cook, 2019; Cook et al., 2015; Dwornik, 2014; Martin et al., 2023); Tapp et al., 2020; Van Denderen et al., 2020). Additionally, this approach aligns with the personal values of forensic healthcare staff, who emphasize that participating in restorative justice encourages individuals to take responsibility for their actions and to contemplate future changes, offering a sophisticated and mature approach (Cook, 2019; Dwornik, 2014; Tapp et al., 2020; Tapp & Verrinder, 2023). Similarly, staff members link the process of restoration to various aspects of their work, including offense analysis, victim empathy, insight development, and self-reflection – all of which are considered to contribute to relapse prevention, risk reduction, and progress towards recovery (Cook et al., 2015).

For offenders, restorative justice interventions led to shifts in emotions, thoughts, and behaviors, fostering an understanding of the harm they caused to victims and encouraging them to take responsibility for their actions (Cook, 2019; Cook et al., 2015; Dwornik, 2014; Martin et al., 2023; Tapp et al., 2020). When asked directly, offenders reported that the restorative justice process helped them reconnect with family, process the offence, contribute to the well-being of their victims and gain self-confidence (Van Denderen & Wolf, 2023). For instance, one offender reported that being able to contribute to his victim’s wellbeing had helped him process his offence (Van Denderen & Wolf, 2023). Similarly, being able to express regret and to apologize helped offenders gain insight in their crime and cope with the consequences (Van Denderen et al., 2020; Cook, 2019). In line with this, engaging in a restorative intervention was perceived by patients as doing something different, being brave, taking responsibility and relating in a different manner to self and others (Cook et al., 2015). Cook et al. argue that restorative justice interventions provide a good fit for changing the repetitive problem-saturated self-narrative in which offenders often become entrenched, by providing the opportunity to do something that can make them proud. Finally, even in cases where victim-offender contact was not established, there can still be therapeutic benefits (Van Denderen & Wolf, 2023). An example is the case of an autistic offender who felt disappointed and frustrated when the victim did not respond to his letter. This experience was incorporated in treatment on how to cope with this frustration (Van Denderen & Wolf, 2023).

Thematic interview analysis

In the interviews, a few common themes are recognizable concerning treatment effects of victim involvement during forensic psychiatric care, namely (1) awareness, (2) motivation and compliance, (3) a more positive self-image, and (4) direct treatment, which we discuss below. In general, victim involvement is considered by interviewees to contribute to safe resocialization.

The clearest theme that emerges from the interviews is that participating in victim-offender interaction contributes to awareness of the offender. It provides a (new) realization of what one has done to another through the offence. It is seen as a learning experience for offenders to literally face the impact of their actions. Victim involvement, more so than a crime-scenario procedure, can be helpful in this. In addition to awareness of one’s own actions, it is mentioned that there is a growing awareness that victims are also bound by the offence for longer periods of time. Also, increased victim awareness makes it more difficult for offenders to deny and downplay the offence and its effects on others.

This awareness can then contribute to motivation for treatment and treatment compliance. Respondents observe that offenders are generally more motivated to change and stay out of trouble after interaction with the victim. It also appears to contribute to making certain agreements with offenders (for instance a restraining order, an area ban or treatment related agreements) and then get the offender to commit to those agreements. Sometimes when treatment compliance is low, a reminder of the victim impact of their offence and tapering into victim empathy can help offenders to realize that it is important to stay on track and comply.

Victim-offender interaction can also positively contribute to the offender’s self-image. The fact that they have done something very difficult and confronting, that they were able to express their regrets, give acknowledgement, take away fear, provide answers and thereby contribute in some way to the victims’ process, bolsters their self-image. According to the respondents, offenders can show that they are not defined by their actions: they ‘can step out of the role of perpetrator and to some extent regain their humanity’. They show both to victims and to themselves that they are more than their crime; their apologies for and recognition of their wrongdoings allows offenders to move on.

Finally, the process of victim engagement can bring certain problems to light that can then become topic of further treatment. In psychotherapy the contact with the victim and victim awareness can be used: how did it affect the victim, and how does this affect you? For instance, negative responses towards the victim or cognitive distortions about the victim or the crime that are still present can become apparent. Often, these problems come to light at an early stage of the process, and are valuable in directing treatment. Another issue is the unwillingness by victims to participate, or during interaction their inability to offer sought-after forgiveness. During treatment offenders can learn how to understand and cope with this response by the victim.

Challenges

Narrative review

The importance of good preparation is clearly highlighted (Dalhuisen & Bosma, 2021; Drennan & Swanepoel, 2022; Tapp et al., 2020; Van Denderen et al., 2020). This process can be time-consuming and may not always be feasible due to capacity problems (Tapp & Verrinder, 2023). Part of the preparation phase is determining the suitability to participate and to adjust the process to any limitations if necessary. Mental health conditions can thus influence the timing of the process. This raises questions about how to best deal with this and what steps should be taken to establish ability to participate if the mental health of participants is in question (Tapp & Verrinder, 2023; Van Denderen et al., 2020). It is important to prevent any further harm to victims as well as to not destabilize the forensic patient. Consequently, fear of further harm and potential risks is a commonly highlighted challenge (Cook et al., 2015; Harvey & Drennan, 2021; Drennan & Swanepoel, 2022; Dwornik, 2014; Tapp & Verrinder, 2023; Van Denderen et al., 2020). For instance, discussions about why some restorative justice referrals for patients were not pursued revealed concerns that the process could be unsettling or was ill-timed (Cook, 2019; Tapp & Verrinder, 2023; Van Denderen & Wolf, 2023). Furthermore, a dilemma may arise between balancing the duty of care to the victim and the knowledge-related assumptions about whether the offender is capable and willing to assume responsibility and make amends (Drennan & Swanepoel, 2022; Tapp & Verrinder, 2023). Moreover, Dalhuisen and Bosma (2021) describe the fact that a significant part of victims is related to the offender as a complicating factor. In those instances, victim-offender contact can result in the restoration of family ties, but family dynamics can also complicate the interaction which calls for a balanced approach and thorough preparation.

The facilitator’s role is also frequently mentioned when addressing challenges in implementing restorative justice in a forensic healthcare setting. Especially in terms of mental health expertise and neutrality (Cook, 2019; Cook et al., 2015; Drennan & Swanepoel, 2022; Harvey & Drennan, 2021; Tapp & Verrinder, 2023). Restorative justice interventions can be facilitated by internal facilitators (mental health practitioners) or external facilitators (e.g. independent mediators), with different roles and responsibilities. Facilitators who are less experienced in the mental healthcare setting express some concerns about effectively managing cases involving offenders with serious mental illnesses and advocate the need for better education (Dwornik, 2014). Especially within forensic healthcare setting, facilitators play an important role in assessing and mitigating potential risk. In this context, facilitators within forensic institutions can contribute by sharing their mental health expertise and their understanding of the organization. However, some patients and victims expressed concerns about the organization’s potential influence on the facilitator (Cook, 2019; Cook et al., 2015). They highlighted the importance of the facilitator appearing impartial to them. One study, in which restorative justice was implemented between patient and staff members following an incident on the ward, found that using one facilitator with relational bonds to the staff members and patients and one facilitator without those connections provided a good balance (Cook, 2019).

Thematic interview analysis

Respondents discuss several challenges to victim-offender interaction in a forensic psychiatric setting. First, although they all stress that much is possible, it should not be forgotten that there are also limitations to victim awareness within this population. One should be realistic about it and about what it can bring. For instance, during the meeting with the victim, offenders may exhibit a lot of empathy for the victim, can show remorse, and offer recognition, but, afterwards, when taking the victim into consideration results in certain restrictions for their leave (e.g. a restraining order) their victim empathy may suddenly be a lot less.

Second, clear contra-indications for contact with victims can be present and must be recognized. For instance, certain offences such as stalking or sexual offences arising from an erotomanic delusion where there is an unhealthy fascination with the victim, or if the contact is expected to cause more harm than good because the offender’s mental capacities are too limited. In those instances, the head practitioner would not give consent. And if an offender is instrumentally motivated and purely acts out of self-interest contact is also contra-indicated, as is the case with denying offenders with no or little awareness of the offence and no recognition of the victim as such.

A third challenge is the timing of the contact. It is important to make sure whether an offender is ready for it, which depends on how far along someone is in the process. This is a somewhat vague description, but it becomes apparent from the interviews that a delict analysis must have been made, ensuring that an offender has gained some insight into his offence and motives. In addition, but related to the previous point, there must be some intrinsic motivation present, even if a therapist takes the initiative to victim involvement. In practice, this often means that an offender has already undergone a number of therapies and treatments. Taking full responsibility for the offence can be difficult due to feelings of guilt and shame resulting in a suppression of personal accountability. Still, even if an offender is able to take responsibility for only part of what happened, respondents stress that this can be valuable for the victim and offer restoration. For instance, the contact may provide valuable answers or just being able to face the offender may be important to victims.

Finally, as described above, transparency towards victims is helpful in expectation management. In other words, some information about the offender’s situation and condition may be valuable for victims before the contact takes place. Meanwhile, an offender has to give consent before information about their pathology can be shared with victims. Forensic social workers involved in treatment are thus restricted by rules of confidentiality that apply in healthcare. For direct contact between victims and offenders consent is needed. For indirect contact, that is contact between victim and forensic psychiatric hospital, the rules that apply are different. If a victim cannot receive specific information about an offender due to lack of consent, social workers may still be able to give general information about the treatment measure, general steps in the forensic treatment measure, leave policy and restrictions.

Discussion and conclusion

The importance of victims’ right to restorative justice is clearly acknowledged in laws and regulations throughout various jurisdictions. However, the implementation of restorative justice services within the context of forensic mental healthcare is still limited. This article aimed to explore the possibilities and challenges for restorative justice services in forensic mental health. As this is still an emerging field of research, with a relatively limited number of studies, we combined a review of the literature and interviews with involved professionals.

Our narrative review and interview study focused on the impact of various diagnoses on victim engagement in forensic psychiatry, the effects of victim-offender interaction on treatment, and challenges for victim-offender interaction (see Table 1). Regarding the first theme, the results clearly indicate that restorative justice can be deployed successfully within the context of forensic mental health care. What is more, not one diagnostic category is excluded beforehand. However, certain characteristics that are often related to pathology must be taken into consideration when deciding on whether or not to engage victims within forensic psychiatry and, in principle, it is advisable to brief victims beforehand on these characteristics so they know what to expect –taking into account relevant privacy regulations. In particular, these characteristics concern the degree of empathy and a sense of conscience, the extent of problem awareness and psychological stability and the sincerity of motives to participate. In addition, psychopathology can affect the offender’s ability to participate in and cope with victim involvement. Regarding the second theme (the effects of victim-offender interaction on treatment), our results show that participating in the restorative justice process can benefit treatment, by increasing victim awareness, by heightening motivation for and compliance to treatment, by strengthening the self-image and by uncovering areas of concern for further treatment. Finally, there are several challenges to restorative justice in forensic mental health. Adequate preparation including expectation management is paramount for success, as are correct timing of the contact and ensuring facilitator impartiality. Furthermore, one should keep in mind that there may be limitations to victim awareness within this offender population.

Table 1. Summary of main findings.

Impact of psychopathology on victim involvement
	Restorative justice is in principle possible with all types of diagnoses
	Specific mental health symptoms are relevant to consider, e.g. impaired reality testing, limited problem awareness, reduced empathy and hampered conscience (possible inauthenticity of motives), psychological instability, the inability to honor agreements
Treatment effects
	Restorative justice processes can have positive impact on recovery and risk reduction
	It may, more specifically, benefit offender-awareness, treatment motivation and compliance, offender self-image and treatment direction
Challenges
	Fear or risk of further harm for both victim and offender, limitations to victim awareness, certain offences (like stalking), mental capacities of offender, no recognition of a victim as such, and timing (not too soon) must be taken into account
	Challenges can be addressed in preparation and during victim-offender contact, but it can be time-consuming and transparency may be restricted by confidentiality rules in healthcare

Our study offers more insight into the opportunities and challenges regarding restorative justice in forensic psychiatry. However, there are limitations. First, as said, the number of included studies is small, which has to do with the fact that this concerns an emerging field of research. Second, only a limited number of respondents were interviewed (yet, saturation was achieved). For future research, we recommend to include larger samples of various stakeholders – including victims and offenders/forensic patients – and to make an explicit distinction between internal and external facilitators. A more fundamental question to address in future research is to what extent the current framework of restorative justice and its associated standards are a good fit within a forensic mental health context, or whether more contextualized standards for forensic mental healthcare have to be developed.

Acknowledgements

This study was partly funded by the Empirical Research into institutions for conflict resolution (ERI) research cluster and the Utrecht Centre for Accountability and Liability Law (UCALL) at Utrecht University.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.