Liz Jamieson, Ph.D; Pamela J. Taylor, F Med Sc; Barry Gibson, Ph.D. Abstract People with mental disorder are admitted to high security hospitals because of perceived risk of serious harm to others. Outcome studies generally focus on adverse events, especially reoffending, reflecting public and government anxieties. There is no theoretical model to provide a better basis for measurement. There have been no studies examining discharge from the perspectives of those involved in the process. This paper begins to fill this gap by generating a grounded theory of the main concerns of those involved in decisions to discharge from such hospitals. Data were collected by semi-structured interviews with staff of various clinical and non-clinical disciplines, some with a primary duty of care to the patient, while mindful of public safety, and some with a primary duty to the public, while mindful of patients’ rights. The data were analysed using a grounded theory approach. Their main concern was ‘pathological dependence’ and that was resolved through the process of ‘facilitating independent living’. Clinicians and non-clinicians alike managed this by ‘paving the way’ and ‘testing out’. The former begins on hospital admission, intensifies during residency, and lessens after discharge. Testing out overlaps, but happens to a greater extent outside high security. Factors within the patient and/or within the external environment could be enhancers or barriers to movement along a dependence-independence continuum. A barrier appearing after some progress along the continuum and ending independence gained was called a ‘terminator’. Bad outcomes were continuing or resumed dependency, with ‘terminators’, such as death, re-offending or readmission, modelled as explanations rather than outcomes per se. Good outcomes were attainment and maintenance of community living with unconstrained choice of professional and/or social supports. Although this work was done in relation to high security hospital patients, it is likely that the findings will be relevant to decision making about departure from other closed clinical settings. KEYWORDS: pathological dependence, independent living, grounded theory, mentally disordered offenders, high security (special) hospitals Background Most countries have special secure healthcare facilities for people with a major mental disorder thought to pose a serious threat of harm to others, generally after at least one serious criminal conviction. It is difficult, however, to compare outcome studies between different countries because laws, policies, social structures and service availability may each vary widely. Facilities may be entirely within the health services, entirely within prisons, or a mixture of the two. Not all countries provide every level of security, and there may be international differences in definitions of ‘high’, ‘medium’ and ‘low’ security. There is, though, common ground in being held in such a secure institution – in constraints to freedom and autonomy within and outside the unit and long enforced proximity to others with grave health and behavioural problems. In England and Wales, people with a major mental disorder, detainable under mental health legislation and thought to pose a high risk of serious and imminent harm to the public, may be admitted to a high security, or ‘special’ hospital. Median length of stay there is over six years (Butwell, Jamieson, Leese & Taylor, 2000). Perhaps the most common ground to date between studies internationally and over time is in choice of outcome measures. Studies in both the United Kingdom and North America, for example, have focused almost exclusively on re-offending (Jamieson & Taylor, 2004; Steadman & Keveles, 1972; Steadman & Cocozza, 1974; Thornberry & Jacoby, 1979; Pruesse & Quinsey, 1977). There is less common ground between nations,...