Forensic Learning Disability Service Research Articles

Who and what supports systemic working in a learning disabilities context?

PHOTO CREDIT: Hannah Busing, UnsplashThis article sets out some of the many ways in which systemic working can find a place in Learning Disability (LD) services. It covers ways in which systemic working can influence different aspects of work in an LD service, possibilities for embedding systemic approaches in Positive Behaviour Support (PBS) work in an Enhanced Support Service (ESS), systemic consultation in an LD team, systemic working in a forensic LD service and a specialist LD family therapy service. We hope the article offers a range of ideas which others can draw upon in thinking about their own context, practice and future possibilities.

Adapting dialectical behaviour therapy in forensic learning disability services: A grounded theory informed study of "what works".

Emerging evidence indicates effectiveness of dialectical behaviour therapy (DBT) for people with intellectual disabilities (PWID) in forensic settings; however, little is known about "what works" facilitating engagement and change. Eleven interviews were conducted with nine service users across two secure inpatient services. Grounded theory was used to develop a model of perceived engagement and change. The model provides insights into how change occurs during DBT delivered in forensic settings. DBT constitutes a challenging journey, yet provides the motivation and means to address individual's intra-/interpersonal aggression and progress towards release. Participants experienced engaging with DBT as difficult and coercive, moving from compliance and avoidance to acceptance and change. Key factors included participants' motivation, beliefs about safety and ability to change, and interactions with staff. Recommendations are made for increasing intrinsic motivation, reducing perceived coercion and distress, and for future research to address potential aversive elements and enhance effectiveness.

Experiences of women with learning disabilities undergoing dialectical behaviour therapy in a secure service

Accessible summary Dialectical behaviour therapy is a “talking” therapy developed by Marsha Linehan. It helps people who are living in the community and also living in hospitals and people who may have problems managing their emotions. In recent years, dialectical behaviour therapy has been used to help people with learning disabilities cope with feelings of anxiety, trauma‐related disorders and mood disorders, but there are not many research papers showing how it is used in forensic learning disability services. This research tells the story of seven women with learning disabilities who took part in dialectical behaviour therapy whilst living in a forensic service. Their story and experiences are important in research literature and will help other services to think about what is needed when they introduce a new type of therapy such as dialectical behaviour therapy .AbstractBackgroundThis research aimed to capture the experiences of women with learning disabilities living in secure services who undertook dialectical behaviour therapy (DBT); they were the first people to do this in the trust. It is hoped their experiences may guide and inform other services undertaking the same process.Materials and MethodsInterpretative phenomenological analysis (IPA) was used to provide a flexible framework to make sense of the way the women interpreted their experiences.Results and DiscussionThe analysis identified three main themes: How you do DBT, What we think about DBT, Using DBT. The qualitative approach adds a valuable contribution to the wider literature, highlighting the importance of capturing the women's voices.ConclusionAs most published literature regarding the effectiveness of DBT is not written from first hand service user experiences, it is hoped this research offers a unique insight into these women's experience.

Resolve: a community-based forensic learning disability service specialising in supporting male sex offenders – our model, approach and evidence base for effective intervention

Purpose The purpose of this paper is to examine a model of effective forensic practice with positive interventions for men with learning disabilities who have committed serious sexual offences. It outlines the theoretical and philosophical frameworks which have informed the model of care and support in a community-based setting and the evidence base for the efficacy of the approach. Design/methodology/approach This approach to a community-based forensic learning disability service is informed by systemic practice and underpinned by models of human occupation (Keilhofner, 2008) which informs occupational therapy and total attachment (Harbottle et al., 2014). This is a whole systems model for developing compassionate and participatory practice based on attachment theory and approaches to professional parenting drawn from foster care settings and prevention frameworks for adult safeguarding. It uses Klinean Thinking Environments (1999) to give practical communication to the model. Findings The attachment model which underpins both the support for staff and the framework for scaffolding the care and support provided for service users is building calm, consistent and respectful relationships. This enables workers and service users to feel accepted through the availability of support; to feel a sense of belonging and inclusion in which skills and confidence can flourish helping all to feel more effective. This is evidenced by the stability of the service user group and the staff team. Research limitations/implications The model of whole system care and support care outlined in this paper can help to provide a therapeutic environment in which men who have committed sexual offences can develop effective skills within a safe, supportive and effectively managed setting. This is on-going research but there is evidence of service users and staff in this model of practice, feeling scaffolded, able to enjoy and achieve progress and personal development. Practical implications This model appears to promote stable, sustained, supportive relationships. Placement breakdown has been minimal indicating that the disruption rate is low and therefore therapeutic interventions are likely to take place and be effective. This is a hopeful and positive approach which enables individuals to flourish in a safe environment. Social implications The social implications of this model are positive for creating a stable workforce in an industry plagued with rapid turn over of staff to the detriment of the quality of life for service users. It creates stability and confidence for the residents allowing them to begin to relax and thereafter achieve more positive relationships. Originality/value This paper examines the application of theoretical frameworks drawn from other disciplines and fuses them into a therapeutic approach to support this service user group. It is a model that can have great portability to other settings but it is its application in forensic services that is new and which is growing its evidence base for its effectiveness.

Journeys into dialectical behaviour therapy (DBT): capturing the staff and service-user experience

Purpose – The purpose of this paper is to explore the lived experiences of staff and service-users regarding the introduction of dialectical behaviour therapy (DBT) into an NHS forensic learning disability (LD) service. Design/methodology/approach – Drawing on data from two recent qualitative research studies, the research team used a case-oriented approach to see beyond original findings to capture the shared experiences of the participants’ journeys, thus giving a deeper insight to the commonalities of the participants’ voices which is rarely reported in the literature (Sandelowski, 2011). Findings – A common set of phenomena became apparent when the cases were analysed, these included: trust, intensity and worthwhile. It is intended this paper gives some opportunity for reflection and shared empathetic responses to the similar experiences discussed. Originality/value – The case-orientated analysis adds value to the evidence base by highlighting the importance of the qualitative voice of both the staff and service user. This is important because most available literature reflects the process of setting up a team or DBT service, rather than describing the team experience. Equally, most published literature regarding the effectiveness of DBT is not written from the perspective of the people who receive the therapy.

The impact of case formulation meetings for teams

Purpose– The purpose of this paper is to investigate the impact of psychological case formulation meetings for staff in a secure forensic learning disability and autism service.Design/methodology/approach– In total, 89 of the attendees completed a questionnaire prior to the formulation meeting and then another questionnaire following attendance at a formulation meeting.Findings– The results indicate that staff found these to be a helpful, informative and a positive experience professionally and personally. The results suggest that the formulation meetings developed staffs’ psychological understanding about the patient and their problems, helped to increase their empathy towards the patient, increased consistency in the teams’ views, and that the staff felt listened to.Research limitations/implications– Psychological formulation meetings are established in the current service, and therefore this may be a contributing to factor to the lack of significant change found in some of the items. Therefore, it would be beneficial for future services to complete a service evaluation at a much earlier point of implementation, as this may impact the level of significance.Originality/value– The findings of this service evaluation suggest that formulation is a beneficial and useful tool for teams and would be a helpful tool for psychologists to use in the clinical work with teams.

Making a difference? Ten years of managing people with intellectual disability and forensic needs in the community

Purpose – Nationally community services for patients with intellectual disability and forensic needs are limited, and research to guide service development for this patient group with highly complex needs is sparse. The purpose of this paper is to provide an overview of referrals to and case management by the multi-agency Fife Forensic Learning Disability Service (FFLDS), including demographic data, treatment, risk assessments and outcomes. Design/methodology/approach – All referrals received between 2004 and 2014 were reviewed to identify key demographic factors and to clarify the outcome of the referrals. Risks levels and presence of factors related to ongoing risk management were identified. For those accepted, final outcomes were noted. Findings – In total, 145 referrals were received by FFLDS between 1 January 2004 and 31 December 2014. Of these 117 were accepted for ongoing case management. In total 106 patients were discharged from FFLDS over the review period, with the vast majority remaining in community settings. Patients were overwhelmingly male, with an age range of 16-79 (mean age of 30). Approximately half of referrals were from criminal justice agencies, and sexual and violent offences predominated. Alcohol and/or illicit substance use was problematic in 49 per cent of patients. Research limitations/implications – FFLDS needs to consider building links with Drug and Alcohol Services, for assistance in developing expertise in managing problematic alcohol and/or illicit substance use. Links with professionals working with female offenders may increase the rate of referral of female patients. Originality/value – Policy and legal frameworks emphasise the need to manage people with learning disabilities and forensic needs in the least restrictive environment possible. This paper provides information on a cohort of forensic patients over a ten-year period, including characteristics and outcomes, to inform the evaluation of these frameworks and the planning of both community and in-patient services for this patient group.

Life Skills Group: increasing foundation knowledge and motivation in offenders with a learning disability

Purpose– Offenders with a learning disability present with greater clinical need than those without a learning disability. However, for this client group, access to and engagement with psychological and criminogenic interventions are often limited. The purpose of this paper is to discuss a potentially useful approach to this issue.Design/methodology/approach– A single case study design was used to evaluate an introductory group programme, delivered over 12 weekly sessions, in a forensic learning disability service. Semi-structured interviews were used alongside psychometric measures, which were completed prior to, and following completion of, the group, in order to assess the individual's experience of the group, their emotional understanding and difficulties, and readiness to change.Findings– Readiness to change and emotional understanding improved following completion of the programme. Self-reported emotional difficulties showed improvement, although not all staff reports corroborated this. Notably, the service user reported a positive experience, with increased confidence and motivation to attend further groups.Research limitations/implications– Generalisation from the results of single case studies is limited. Although results suggest that motivation to engage further has increased, more research is required to assess whether this impacts on actual ability to engage.Practical implications– Offering an introductory programme prior to further, more criminogenically focused intervention may be more effective than offering these interventions as the first stage of treatment.Originality/value– An introductory group programme may be potentially helpful in providing the foundation knowledge, confidence and motivation necessary to attend further intervention focusing on criminogenic need for offenders with a learning disability.

Assessing the probability of patients reoffending after discharge from low to medium secure forensic mental health services: An inductive prevention paradox

Citizens of developed societies are troubled by those who commit ‘irrational' crimes against the person. Reoffending by ex-patients following their release from secure mental health services triggers particularly intense angst when amplified by media and political scrutiny. Forensic mental health service providers are expected to minimise the occurrence of such transgressions by releasing only those patients who are judged acceptably unlikely to reoffend. However, reoffending probabilities can only be estimated by observing behaviour in secure institutional settings designed specifically to prevent patients from transgressing. The article explores this ‘inductive prevention paradox' which arises when the implementation of measures designed to avoid an adverse event obscures direct observation of what might have happened if prophylaxis had not been attempted. The analysis presented draws on data obtained in 1999–2003 from two qualitative studies in medium to low secure UK institutions, one providing forensic mental health services and the other forensic learning disability services. We explored the views of 56 staff members and 21 patients about risk management in forensic services and undertook additional 25 staff interviews for case studies of the 21 patients. The wider applicability of the inductive prevention paradox will be considered in the Discussion. We argue that the prognostic limitations arising from prevention have been underestimated by policy makers and in official inquiries; and that the prevailing personal risk assessment framework needs to be complemented by greater attention to the environments which patients will be discharged into.

Shaping Service Design: Developing a forensic learning disability service

Shaping Service Design: Developing a forensic learning disability service

The “forensicisation” of challenging behaviour: the perils of people with learning disabilities and severe challenging behaviours being viewed as “forensic” patients

PurposeIn Scotland, following the closure of long stay learning disability hospitals in 2005, focus has shifted on to developing robust community services/resources to cater for the healthcare needs of people with learning disabilities. In the absence of robust in‐patient services, a small number of individuals with learning disabilities and associated severe challenging behaviours, despite not being regarded as “forensic” cases, do inappropriately get referred and sometimes admitted to forensic learning disability services. This study aims to explore this area of clinical practice in the context of referrals to the high secure forensic setting of The State Hospital, Carstairs, Scotland and in light of key UK and Scottish Government policies.Design/methodology/approachAll referrals made to the State Hospital's forensic learning disability service between August 2005 and July 2010, which met the criteria, were reviewed (n=5) and common determinants leading to these referrals identified and thematically analysed.FindingsThe identified determinants leading to the making of these referrals were broadly classifiable into psychiatric, environmental and staffing themes.Practical implicationsIn Scotland, there does appear to be a requirement for a specialist in‐patient service to meet the needs of this complex and challenging group of patients. There is a need for effective supra‐regional planning to meet the needs of similar “high cost, low volume” patient groups.Originality/valueThis study highlights the wider issue of “gaps” within services in Scotland for individuals with severe challenging behaviours and autism and the requirement for a national specialist service.

Forensic learning disability nursing role analysis

Accessible summary For nurses working with people with a learning disability in forensic settings (possibly having committed a criminal act), it is thought that they need different skills than those nurses in general learning disability settings. Research in forensic nurses working in mental health secure settings suggest that they nurse according to six themes. This research study tested this six theme framework for forensic learning disability nursing. Whilst some of the themes were relevant for nurses working in forensic learning disability services, some were not relevant. SummaryThis article reports on a study carried out on the role constructs of forensic and nonforensic Learning Disability Nursing in relation to six binary themes. The aims were to identify if there were differences in perceptions of forensic learning disability nurses and nonforensic learning disability nurses in relation to the six binary themes of the role construct framework and then to establish if there were differences between the two groups of nurses. The method was a survey design with the sample drawn from high, medium and low security settings and nonsecure settings in the UK. From 400 questionnaires distributed, response rates of 46% and 49% were achieved from secure and nonsecure settings, respectively. The results indicate that the forensic nurses group show a significant difference between ranked scores on a number of themes but no significant difference was found between scores on one of the themes. The nonforensic nurses group also showed a significant difference between scores on a number of the themes but no significant difference was found between scores on a number of themes. Finally, the results of the between group analysis show a significant difference between forensic and nonforensic groups scores on several themes but these are few in number. The conclusions drawn are that whilst there is some support for the relevance of the themes in relation to learning disabilities in the forensic setting, there is less support for nonforensic settings.

Redesigning and evaluating an adapted sex offender treatment programme for offenders with an intellectual disability in a secure setting: preliminary findings

PurposeThe purpose of this paper is to describe a study which investigated the diverse needs of multiple stakeholders in an adapted sex offender treatment programme (ASOTP) and then evaluated a pilot programme set up to respond to the identified needs efficiently and effectively. The paper reports on an innovative approach to delivering ASOTP in secure learning disability services. It aims to address many of the criticisms and concerns of conventional closed format programmes, particular in the climate of value for money and payment by results.Design/methodology/approachThe multiple views of stakeholders were identified by means of questionnaires and semi‐structured interviews in order to ascertain the key issues necessitating change. Stakeholders included purchasers of Partnerships in Care Learning Disability Services (PiC LDS), referred clients, internal and external clinicians involved in their care, group facilitators and, in some cases, clients' families or advocates. A rolling format ASOTP (based on the content of the Prison and Probation Service ASOTP) was designed and piloted to address highlighted needs, including time frames for the commencement and completion of treatment.FindingsInitial feedback obtained by means of structured interviews and discussions with all stakeholders has been positive. In particular, participants have shown an increase in motivation, knowledge, and, unexpectedly, enhanced levels of risk disclosure. Facilitators have reported increased satisfaction and decreased stress levels. These findings are tentative in light of the small numbers involved and the absence of a randomised control trial.Research limitations/implicationsThis study has a number of implications for future research in terms of improving treatment effectiveness by means of increasing knowledge retention and enhancing risk disclosure, as well as a reduction in facilitator burnout.Originality/valueThe programme was tailored to respond to individual treatment needs within a group setting whilst ensuring programme integrity and effective risk management within a forensic learning disability service.

‘Change can only be a good thing:’ staff views on the introduction of a harm minimisation policy in a Forensic Learning Disability service

Accessible summary • Staff were asked for their views on using harm minimisation with people with a learning disability who self-harm. • Staff felt that this policy could benefit some but not all of the clients. • They felt that staff and clients should be able to choose whether to be involved in using harm minimisation. • Staff were mostly in favour of harm minimisation but were worried about the level of their responsibility. Summary Recent local research about personal experiences of self-injury and discussions about the use of harm minimisation with service users who self-injure were the motivation behind this study to glean staff opinions and advice about the introduction of a harm minimisation policy. An online survey was designed, and all staff were invited by email to take part. The survey used multiple-choice questions as well as providing room for open comments. Eighty-five per cent of the seventy-one staff that responded were in favour of the introduction of a harm minimisation policy. Common requests for inclusion were: clear, individualised guidelines that include roles and responsibilities, staff and client support systems, client education and staff training and advice about duty of care issues. This exercise has been invaluable in the production of a harm minimisation policy. Services should consider implementing this type of policy on an individual basis.

Establishing a Work-Based Learning Programme: Vocational Rehabilitation in a Forensic Learning Disability Setting

This paper is a reflective account of a work-based learning programme designed for patients within a forensic learning disability service. The literature review indicated a shortage of published work in this field and reference is made to developments in mental health settings. A commentary is provided of the three partners involved and the working relationship between the hospital, the workplace and the further education college. As a specific vocational rehabilitation programme, it was important to consider the context of a work placement and the process of introducing an award-bearing course. The paper provides a description of the current developments in the qualification structure at entry level and the progress of a pilot group. Views were sought from the patient group about their involvement in the programme and the advantages of collaborative work are stated, with the joint delivery by an occupational therapy student, a teacher and the nursing team. It is suggested that the narrative of this paper could be built on, with the application of an assessment tool to provide a quantitative analysis of the impact of the programme. It is the intention that the descriptive elements of the paper will inform other practitioners and contribute to a model of good practice.

Diagnostic information and adversity in childhood for offenders with learning disabilities referred to and accepted into forensic services

Several studies have related diagnostic information and adversity in childhood to criminal careers and risk of recidivism. Notably, ADHD and conduct disorder in childhood, schizophrenia, sexual abuse and physical abuse have been associated with offences in adulthood. This study investigates these variables in relation to large cohorts of offenders with learning disabilities. A case note review was undertaken for 126 individuals referred but not accepted into forensic learning disability services and 197 individuals accepted for such services. Results are reported on diagnostic information and experience of adversity in childhood. ADHD/conduct disorder featured prominently in both groups. Autistic spectrum disorders were not particularly over‐represented. For adversity in childhood, general socioeconomic deprivation featured prominently in both groups. This also increased significantly for those accepted into services. Sexual abuse and non‐accidental injury were featured at around 13‐20% for both groups. These results are broadly consistent with the mainstream literature on offending, ADHD/conduct disorder and general deprivation featuring significantly in all groups and rising for those accepted into offender services. It is important to deal with these aspects during assessment and to provide appropriate psychotherapeutic services for these individuals.

A survey of learning disability inpatient services in Scotland in 2007

A national review of learning disability services in Scotland, The Same As You? recommended that Health Boards should close all long stay beds by 2005 and reduce assessment and treatment places to specified levels. A psychiatry-led service planning study was carried out in 2007 to find out whether these recommendations had been met. The extent of delayed discharges was also investigated. All 15 Health Boards in Scotland responded and supplied the requested information. There were 388 adults with learning disabilities within inpatient services, 91 of whom were within forensic learning disability services. The age, gender, reasons for admission and length of stay are reported for this inpatient population. Recommendations are made for future recording of delayed discharges and the adequacy of the number of assessment and treatment inpatient places in Scotland is discussed.

Learning disability and forensic mental healthcare in 19th century Ireland.

The Irish College of Psychiatrists recently reported that "the needs of people with learning disability and offending behaviour pose a huge challenge to service providers. The vulnerability of people with a learning disability who come into contact with the criminal justice system is well described and noted." The College noted that "the population with learning disability who offend does not easily fit into existing services" and reported that "the majority of service providers strongly supported the urgent development of a forensic learning disability service." The challenges presented by individuals with learning disability and offending behaviour are not specific to Ireland or to this period in history. The purpose of the present paper is to explore issues related to learning disability and offending behaviour in 19th- and early 20th-century Ireland. More specifically, this paper presents original, previously unpublished case material from the archival medical records of the Central Mental Hospital, Dublin in order to illustrate specific aspects of the institutional experience of individuals with learning disability who were charged with offending behaviour in nineteenth-century Ireland. The Central Mental Hospital, Dublin was established as the Central Criminal Lunatic Asylum in 1845 under the provisions of the Lunatics Asylums (Ireland) Act (1845). Individuals were to be committed to the Central Criminal Lunatic Asylum if they were declared 'guilty but insane' at time of trial or offence, or if they developed mental illness and became difficult to manage while in detention elsewhere. The Central Criminal Lunatic Asylum opened its doors to admissions in 1850 and by 1853 there were 69 male and 40 female inpatients.

Staff attitudes towards patient‐to‐patient bullying in a secure learning disability population: a study of sex differences

The current study explored staff attitudes towards patient‐to‐patient bullying in a forensic learning disability service housing male clients, and the potential role of empathy. One hundred staff took part (51 men and 49 women). All completed the Attitudes towards Bullying scale ‐ Secure version (AB‐S) and the Interpersonal Reactivity Index (IRI). It was predicted that women would report more positive attitudes towards victims of bullying than men, and that increased empathy would be associated with decreased negative attitudes. It was also anticipated that increased length of service would be related to an increase in negative attitude towards victims. The results are discussed with regard to the environment in which bullying is taking place with suggestions for interventions.

Training for plurality ‐ developing modern multi‐professional forensic practice

In contemporary forensic mental health and learning disability services effective care and risk management, which is safe for individuals and the public, can only be delivered by drawing upon differing perspectives and interventions. In practice uni‐disciplinary training abounds, but the authors found a lack of formal training inherently constructed to be multidisciplinary. Therefore, a course was developed, in conjunction with a university partner, to meet this need. This modular course is flexible in nature, but is normally delivered over one semester leading to certification. In addition, there is the option of either essay or portfolio submission providing access to credits toward other academic awards. This programme of study, ‘Professional Practice in Secure Environments’ was recently cited as an example of good practice in From Values to Action, the CNO review of mental health nursing (NIMHE, 2006). Modules begin from a foundation of theory and relate it intimately to practice; students develop an understanding of multidisciplinary working by both training together and training in each others' conceptual frameworks. Participants to date include those from health, criminal justice, and social care arenas, and those with no previous higher study have submitted essays. Evaluations are positive and are used to refine delivery and content. The authors conclude that the course demystifies practice and academia, and provides access to both. This is an integral part of the training strategy, which is directed to meeting current and future service needs.Current and future developments and expansion of forensic mental health provision into new types of service will be less effective without a move away from traditional educational approaches. Services to meet the specific needs of groups such as secure long‐stay and personality disorders cannot be sustained effectively without a parallel development of new types of training.The strategic thinking behind this course, practical obstacles encountered, and solutions developed are described in this paper.