Forensic Mental Health Service Users Research Articles

A Qualitative Exploration of Service Users’ Experiences of Violence Risk Assessment and Management in Forensic Mental Health Settings: An Interpretative Phenomenological Analysis

ABSTRACT Violence risk assessment and management is central to the lives of forensic mental health service users. Whilst studies have explored mental health professionals’ experiences of violence risk assessment and management, research regarding service user views is largely absent from the literature. Using Interpretative Phenomenological Analysis, the current study interviewed seven forensic mental health service users in low secure mental health inpatient settings about their experiences of violence risk assessment and management. Interviews were recorded, transcribed, and analyzed. Results identified four superordinate themes; Who is this for?, Power, Misunderstood, and Moving Forward. The results are discussed in relation to existing literature. Clinical implications and future research directions are then considered.

Linking the past and the present: service users’ perspectives of how adverse experiences relate to their admission to forensic mental health services

PurposeThis study aimed to explore how forensic mental health service users make sense of their past adverse experiences. Secondly, it aimed to explore whether service users considered their adverse experiences to be related to their current stay in a forensic mental health setting.Design/methodology/approachInterpretative phenomenological analysis was used to analyse interviews with eight service users in low and medium secure care. Six of the participants were male and two were female.FindingsFour super-ordinate themes emerged from the data: “Living amongst adversity”; “Managing adverse experiences”; “Making sense of going into secure care”; and “Coping with the past in the present”. All participants referred to multiple adverse experiences throughout their lives and used harmful coping strategies to manage these. Individual differences in how they related their past experiences to their detention in secure care were evident.Practical implicationsAuthor guidelines state that this section is optional. Implications for clinical practice are discussed at length in the discussion section.Originality/valueThis study offers an insight into the way in which forensic mental health service users make sense of their past traumas in relation to their current admission to secure services. To the best of the authors’ knowledge, no research has previously addressed this from the perspective of service users.

Personal recovery and its challenges in forensic mental health: systematic review and thematic synthesis of the qualitative literature.

There has been a call for a framework to guide recovery-oriented practices in forensic mental health services. This study aims to examine personal recovery and its challenges in forensic mental health settings in relation to the established framework for personal recovery in mental illness: connectedness, hope, identity, meaning and empowerment (CHIME). This study is an updated and expanded systematic review and thematic synthesis of the qualitative literature. A systematic search of six electronic databases (Web of Science, Medline, PsycINFO, CINAHL, EMBASE and SocIndex) was carried out in January 2019, using the terms [Recover*] AND [Forensic OR Secure] AND [Patient* OR Offend* OR Service User*]. Only studies that included service user's own perceptions and were published from 2014 onward were included in the review. Data were examined with thematic synthesis and subsequently analysed in relation to the CHIME framework. Twenty-one studies were included in the review. Findings suggest that some adjustments to the original CHIME framework are needed for it to be more relevant to forensic populations, and that an additional recovery process regarding feeling safe and being secure (safety and security) could be added to CHIME, providing the CHIME-Secure framework (CHIME-S). Specific challenges and barriers for forensic recovery were identified and found to represent the opposite of the recovery processes defined by CHIME (e.g. hopelessness). We present the CHIME-S as a framework for the personal recovery processes of forensic mental health service users. The CHIME-S may guide the recovery-oriented work of forensic mental health services.

Improving Psychological Interventions from the Perspective of Forensic Mental Health Service Users: A Meta-synthesis

ABSTRACT Limited evidence exists for the effectiveness of psychological interventions that target the mental health needs of people who use forensic mental health services. Capturing service users’ perspectives and experiences may provide information helpful to understanding why this is the case. It may also provide information that could help to improve the effectiveness of such interventions with this population. This paper aimed to address this and reviewed qualitative studies to identify the factors that are considered important to the effectiveness of interventions from the perspectives of service users. A review of the literature was conducted and eleven papers were identified as meeting the inclusion criteria. A meta-ethnography approach was used to synthesize the data. Six super-ordinate themes emerged which were synthesized into a hierarchy of treatment based on two main categories: “Treatment Foundations” and “Treatment Benefits.” The findings suggested that addressing the Treatment Foundation factors such as enabling informed decision-making; developing trusting therapeutic relationships; and providing accessible materials whilst considering service user preferences can in turn result in service users benefitting from treatment in a number of ways. The findings have significant implications for future research, mental health service providers, clinicians and therapists, and for those who design therapeutic interventions.

Is there adequate evidence to support the use of compassion focused therapy group interventions with forensic mental health service users? A rapid evidence assessment

Compassion focused therapy (CFT) is a model of psychotherapy based on cultivating the capacity for compassion to others and self. The evidence base has grown considerably in the last decade regarding CFT’s effectiveness for a range of mental health problems. However, the literature supporting CFT as a treatment provision for forensic service users with mental health needs is lacking despite the observed overlap in needs between this population and their non-offending clinical counterparts. This rapid evidence assessment (REA) sought to evaluate the current evidence of CFT’s effectiveness as a group therapeutic intervention with clinical populations to allow consideration of the use of CFT with individuals with both mental health and criminogenic needs. A search of electronic databases was undertaken and after a process of review and extraction 10 papers were included. These studies showed promising effects of group-level CFT for those with complex mental health needs. Some evidence emerged of CFT generating significant improvements compared to no treatment and treatment as usual (TAU), but insufficient evidence has been produced in respect of whether CFT can supersede traditional ‘gold-standard’ approaches such as Cognitive Behavioural Therapy (CBT). Tentative conclusions are made regarding the applicability of CFT interventions but the observed reductions in shame and self-criticism and a move towards more guilt-based motivational drives suggest that this approach shows some promise in being able to assist forensic service users in taking more responsibility for their harmful actions and foster social and affiliative processes with others. Further high quality RCTs are needed in order to make firm conclusions about the clinical utility of this therapy for forensic populations with mental health needs.

Health behaviours of forensic mental health service users, in relation to smoking, alcohol consumption, dietary behaviours and physical activity-A mixed methods systematic review.

People with mental disorders have increased risk of dying from diabetes and cardiovascular diseases compared to the general population. Diabetes and cardiovascular diseases are preventable by improved lifestyle regarding smoking, alcohol consumption, physical activity and dietary behaviours. Forensic mental health service users are treated for longer periods of time compared to non-forensic mental health service users, giving the opportunity to affect the lifestyle for a substantial period of time. This review gathers existing research on forensic mental health service users' lifestyle regarding smoking, alcohol consumption, physical activity, and dietary behaviours and factors influencing it. The lifestyle was found to be unfavourable with many patients being smokers, having problematic alcohol consumption, being physically inactive and eating a diet of poor nutritional value and rich in calories. Therefore, it seems likely that an unfavourable lifestyle is one reason for the excess mortality from diabetes and cardiovascular diseases. Smoking cessation and improving dietary habits was perceived difficult, but nicotine replacement and practical advice was suggested to support a change. The treatment period gives an opportunity to improve the lifestyle of forensic mental health service users to prevent diabetes and cardiovascular diseases in this high-risk group. We recommend a holistic approach, when planning the prevention activities, since activities that are perceived fun are more likely to succeed. Introduction People with mental disorders have increased risk of dying from diabetes and cardiovascular diseases, both of which can be prevented by lifestyle. Aim To review existing research, in order to investigate the characteristics of, and factors that influence forensic mental health service users' (FMU) health behaviours. Method We searched PubMed, CINAHL, PsycInfo and Scopus for primary research on FMU's health behaviours regarding smoking, alcohol consumption, physical activity and dietary behaviours, and factors that influence them. Results We found 13 eligible studies. The findings consistently indicated the presence of unfavourable health behaviours in FMU: Smoking, problematic alcohol consumption, physical inactivity and a high-calorie diet of poor nutritional value. Changing smoking and dietary habits was perceived as difficult, but nicotine replacement and practical advice were suggested to support change. Discussion The existing research on FMU's health behaviours is sparse. In particular, there is a lack of research on factors that influence health behaviours. From our findings, it seems likely that FMU's unfavourable health behaviours contribute to their increased risk of dying from diabetes and cardiovascular diseases. Implications for practice FMU's health behaviours should be improved to prevent diabetes and cardiovascular diseases in this high-risk group.

Eye movement desensitization and reprocessing (EMDR)\xa0therapy for posttraumatic stress disorder in adults with serious mental illness within forensic and rehabilitation services: a study protocol for a randomized controlled trial

BackgroundEye movement desensitization and reprocessing (EMDR) is an evidenced-based treatment for posttraumatic stress disorder (PTSD). Forensic mental health services provide assessment and treatment of people with mental illness and a history of criminal offending, or those who are at risk of offending. Forensic mental health services include high, medium, and low-security inpatient settings as well as prison in-reach and community outpatient services. There is a high prevalence of PTSD in forensic settings and posttraumatic experiences can arise in people who violently offend in the context of serious mental illness (SMI). Successful treatment of PTSD may reduce the risk of relapse and improve clinical outcomes for this population. This study aims to assess the efficacy, risk of harm, and acceptability of EMDR within forensic and rehabilitation mental health services, as compared to treatment as usual (routine care).MethodsThis is a single-blind, randomized controlled trial comparing EMDR therapy to the waiting list (routine care). Adult forensic mental health service users (n = 46) with SMI and meeting the criteria for PTSD will be included in the study. Participants will be randomized after baseline assessment to either treatment as usual plus waiting list for EMDR or to treatment as usual plus EMDR. The EMDR condition comprises nine sessions, around 60 min in length delivered weekly, the first of which is a case conceptualization session. The primary outcomes are clinician and participant-rated symptoms of PTSD, and adverse events. Secondary outcomes include psychotic symptoms, social functioning, level of disability, self-esteem, depressive symptoms, post-trauma cognitions, and broad domains of complex posttraumatic difficulties. A trained assessor blinded to the treatment condition will assess outcomes at baseline, 10 weeks, and 6 months. Additionally, grounded theory qualitative methods will be used to explore participant experience of EMDR for a subset of participants.DiscussionThis study will contribute to the currently limited evidence base for EMDR for PTSD in forensic settings. It is the first randomized clinical trial to assess the efficacy, risk of harm, and acceptability of EMDR for PTSD in people with SMI in either forensic, mental health inpatient, or custodial settings.Trial registrationAustralia and New Zealand Clinical Trials Network, ACTRN12618000683235. Registered prospectively on 24 April 2018.

‘Monsters don’t bother me anymore’ forensic mental health service users’ experiences of acceptance and commitment therapy for psychosis

ABSTRACTAcceptance and Commitment Therapy for psychosis (ACTp) is an approach that aims to change the relationship an individual with psychosis has with difficult thoughts, emotions and experiences. It promotes the use of acceptance, defusion, mindfulness and focussing on valued outcomes as opposed to struggling with psychotic experiences. This service evaluation project explored service users’ experiences and meanings of ACTp within a medium secure mental health service. Thematic analysis was used to analyse interviews with 10 male service users. Four main themes emerged from the data: ‘Recovery’, ‘Insight’, ‘Developing Skills’ and ‘Accessibility’. Overall, service users viewed their experience of ACTp positively and identified encouraging therapeutic outcomes. These findings suggest that ACTp is an approach that should be considered a therapeutic option within forensic mental health contexts. These outcomes were compared with previous research findings. Limitations of the study, clinical implications and ideas for future research have been discussed.

Making sense of being recalled: a grounded theory

Purpose A high proportion of forensic mental health service users (FSUs) are recalled to secure hospitals from conditional discharge in the community. The limited research on recall to date has preliminarily identified why FSUs are recalled, but not how they make sense of the process. The purpose of this paper is to develop a conceptual understanding of how FSUs make sense of being recalled to hospital. Design/methodology/approach A constructivist grounded theory approach was used. Semi-structured interviews were carried out with 11 FSUs from different levels of forensic service security who had been recalled varying numbers of times across a wide timeframe. Findings A theoretical model was constructed to illustrate the process of how FSUs make sense of being recalled. FSUs appraise being recalled on a continuum from negative to positive, based on their experiences when conditionally discharged and their reflections on the circumstances of being recalled. The nature of their appraisal appears to reciprocally influence their subsequent attitudes towards and their engagement with forensic services. Research limitations/implications The proposed mechanism of how FSUs make sense of being recalled, particularly their dynamic appraisal of it, should now be investigated longitudinally. Future qualitative research could explore forensic service staff perspectives on recall. Practical implications Enhancing the positivity of FSUs’ appraisals about being recalled may improve their attitudes about and engagement with forensic services. Originality/value This is the first research study to construct a theoretical model of recall.

An evaluation of an employment pilot to support forensic mental health service users into work and vocational activities

Background: Few employment programmes exist to support forensic service users with severe mental health problems and a criminal history. Little is known about how best to achieve this. The Employment and Social Inclusion Project (ESIP) was developed and piloted to support forensic service users into employment and vocational activities.Aims: This pilot service evaluation aimed to assess the number of service users who secured employment/vocational activities and explored services users’ and staff experiences.Method: Quantitative data were collected to record the characteristics of participating service users and how many secured employment and engaged in vocational activities. Eighteen qualitative interviews were conducted with service users and staff.Results: Fifty-seven service users engaged with the project, most were men (93.0%) and previously employed (82.5%). Four service users (7.0%) secured paid competitive employment. Eight (14.0%) gained other paid employment. Tailored one-to-one support to increase skills and build confidence was an important feature of the project. Creation of a painting and decorating programme offered training and paid/flexible work.Conclusions: This exploratory project achieved some success in assisting forensic service users into paid employment. Further research to identify what works well for this important group will be of great value.

StreetWise: developing a serious game to support forensic mental health service users' preparation for discharge: a feasibility study.

Introduction Assessment of users' skills and confidence to safely respond to risky community-based situations underpins discharge planning. Serious games have been used for skills development, and this study trialled their use in forensic mental health services. Aim The aim was to develop and test the acceptability and usability of an innovative serious game to support forensic mental health service users' preparation for discharge. Method A prototype serious game was developed by service users and researchers. Acceptability and usability testing was undertaken and service providers interviewed about the acceptability of serious gaming for forensic mental health services. Result A prototype game was produced and successfully trialled by service users. However, both service users and providers identified that work needed to be done to develop and test a game with greater complexity. Discussion The acceptability and usability of using serious games to support service users to develop skills needed for successful discharge was demonstrated. Implications for practice Mental health practitioners may use gaming to support their practice and work innovatively with other professions such as game developers to create new ways of working in forensic mental health services.

“Supporting me through emotional times, all different kinds of behaviour.” Forensic mental health service users understanding of positive behavioural support

This service evaluation project explored service users’ experiences of positive behavioural support (PBS) within a medium secure mental health service. Interpretative phenomenological analysis (IPA) was used to analyse interviews with ten service users. Four main themes emerged from the data: My plan; How I understand PBS; How PBS has helped me, the benefits; and Making the plan work. Overall, service users viewed their experience of having a PBS plan positively. They reflected that the plans offered staff greater understanding of their behaviours and needs, enabling them to receive appropriate support. Service users valued the experience of being involved in the process, offering important insights into their experiences. They also expressed frustrations about staff not following the plan and not understanding why they had a plan whilst others did not. Limitations of the study, clinical implications and ideas for future research have been discussed.

Mental illness and parenthood: being a parent in secure psychiatric care.

BackgroundResearch into parenting and mental illness seldom includes forensic mental health service users, despite its relevance to therapeutic, family work and risk management.AimsThis study aimed to understand the experiences of parents and the variety of parenting roles maintained during admission to a secure forensic hospital.MethodsNarrative interviews with 18 parents (eight mothers and 10 fathers) at an English medium security hospital were analysed thematically, using the framework approach. The proportion of patients who are parents and their contact patterns with their children were estimated from records.ResultsAbout a quarter of men and 38% of women were parents. Parenthood was of central importance to their emotional life, spanning experiences of loss, shame and failed expectations, joy, responsibility and hope. Fewer fathers maintained contact with their children than mothers yet fatherhood remained a vital aspect of men's identities, with impact on their self-esteem. Parenting during lengthy admissions – while constrained and dependent on professional support and surveillance – ranged from sending gifts and money to visits and phone calls. Offending was seen as a particularly shameful aspect of admission, contributing to distancing from the children and difficulty explaining detention to them.ConclusionsSuch complex experiences call for multidisciplinary knowledge and skills. Provision of focused therapy, as well as appropriate visiting spaces, creative approaches to contact time and support for patients in explaining their mental illness and detention to their children are recommended. © 2015 The Authors. Criminal Behaviour and Mental Health published by John Wiley & Sons Ltd.

StreetWise: A Valid Ecology for a Serious Game in a Secure Forensic Mental Health Setting

To ascertain their readiness to be discharged from care, secure forensic mental health service users are often given restricted access to their local communities. However, this can be stressful for the service user and expose the public to potential risks. Therefore, new research was undertaken to explore whether a computer-based serious game could enable service users to explore their responses to community based risk situations in a safe environment. Creating a serious game for use in a secure forensic mental health setting is itself both novel and problematic, and the initial research sought to test the feasibility and acceptance of the game. This paper reports first results from working with service users to develop a prototype game that accurately describes their experiences and expectations to lay the foundations for a clinically effective tool and achieve acceptance.

Playing the game: service users’ management of risk status in a UK medium secure forensic mental health service

In this article we examine how forensic mental health service users actively attempt to manage their risk status through playing the game of containing frustration and demonstrating compliance. The article draws on an observational study (2006 to 2009) which explored the practices of risk assessment and management within one inner city forensic mental health medium secure service in the UK. We used a grounded theory approach to explore service users’ and providers’ experiences of risk assessment and management. We interviewed forensic mental health service users and providers. We also collected data using participant and non-participant observation. Since access to forensic mental health services is tightly controlled, there are participant-observation studies undertaken in these settings.We found that service users attempted to understand the system of assessment and sought to affect and reduce their risk status by engaging in overt, compliant behaviours. We argue that in doing so service users are active agents in the process of risk management. However, we indicate that there are adverse effects of this approach to risk management as the risk-assessment process is subverted by the restriction of the flow of information, and service users are left with frustrations that they must contain and manage.

Housing Preferences of Irish Forensic Mental Health Service Users on Moving into the Community

Housing is one of the important services required by forensic mental health service users on reintegration into the community. In the Republic of Ireland, a recent amendment to Section 13 of the Criminal Law Insanity Act (2006) has given the prospect of conditional discharge, which has increased the need for housing among Irish forensic mental health service users. This article reports findings of a qualitative descriptive study aimed to explore the housing preferences of these service users. While identifying and capturing their views, the study also identified the strengths and weaknesses of current housing services from a service user perspective. Data were collected from nine service users using semistructured interviews. Colaizzi's (1978) approach was used to analyze the data. Three themes that emerged from the analysis are as follows: (a) living choices; (b) future considerations; and (c) service users' expectations. Although concerns were raised regarding legislation and policy, service users strongly preferred normal independent living and recommended continued community support, gradual discharge, and community hostels. Findings suggest that service users' expectations may be fulfilled with effective collaboration between forensic mental health service and housing services. This is the first study to be carried out in Ireland that adds a new dimension to the literature on housing policy and service users' perspectives.

‘Telling their stories’ on a dual diagnosis training course: Forensic mental health service users' perspective on their challenges, benefits and future strategies

A five day training course on dual diagnosis was developed by the authors in 2008 and delivered annually within the Irish forensic mental health service. Service users were invited to tell their stories on the training course. Literature suggests several therapeutic outcomes for service users such as raised self esteem, empowerment and new insight into their problems. However little is known from an Irish service users' perspective. This qualitative descriptive study was aimed at exploring the experiences of service users' telling their stories on a dual diagnosis training course. Data was collected using one-to-one interviews from seven service users. Qualitative data was analysed thematically. Three themes emerged from the analysis: the benefits, the challenges for the service users and strategies for their future involvement. Service users reported psychological, personal and social benefits and there were perceived benefits for the learners. Public speaking, preparing for the talk and taking questions from the trainees were the main challenges. They suggested several strategies for overcoming challenges in the future courses. In this article, while the authors discuss the need for empowering service users and providing them with adequate support, there are also practical and useful suggestions for the course coordinators/nurse educators. Authors recognise that service user involvement requires extensive time and significant support in preparing and training for their participation which may impact upon resources.

Exploring forensic mental health service users' views on work: an interpretative phenomenological analysis

PurposeThis paper aims to capture the views of forensic mental health service users; focusing on how services promote the aspiration to work, the development of skills for work, and the vocational rehabilitation process. It seeks to provide insight into forensic mental health service users' views on the barriers and enablers to accessing work together with suggestions for enhancing practice, and implications for further research.Design/methodology/approachTen participants from a range of forensic mental health services throughout Scotland took part in semi‐structured interviews. Participants were involved in either paid work, voluntary work or work preparation. Interpretative phenomenological analysis (IPA) allowed exploration of an individual's lived experiences and how they make sense of this.FindingsService users valued the opportunity to address vocational issues at the earliest opportunity in their rehabilitation. Work had an overwhelmingly positive impact on mental health. Analysis of interview transcripts revealed three master themes: “Normalising my life”: the positive impact of work; “Gradual steps”: facing barriers; and “Practical help and encouragement”: feeling supported. There is much to gain from good multidisciplinary rehabilitation within secure hospitals and the community, with work playing an important role in recovery and symptom control. Forensic services should focus on employment and the aspiration to work early, demonstrating awareness that attitude and the aspiration to work are a much more reliable indicator of success than diagnosis and mental health symptoms.Originality/valueFew qualitative studies have investigated service users' views of work within forensic mental health, yet such information can be crucial to enhance and improve service delivery.

Values and health risks: An editorial

This special issue is the second in a four-part series Health Care Through the ‘Lens of Risk’ focussing on risk categorisation, valuing, expecting and time-framing, respectively, and published or to be published in 2012–2013. The present editorial introduces the issue of risk valuing in relation to an interview-based article and five substantial research papers (one appearing in a subsequent issue (14.6) due to space limitations). It will be argued that the notion of ‘adverse event’ projects negative value onto events themselves, directing attention away from the observer's active judgemental role. The relocation of value judgements in the perspectives of social actors allows their potential variability to be more clearly recognised. This issue will be explored in the editorial which introduces papers concerned with hard drug consumption, self-hurting, the community rehabilitation of forensic mental health service users who have committed serious offences against other persons, the treatment of anal cancer and the perspectives of young pregnant women. A common theme linking these papers is the positive valuing of risk-taking officially designated as unacceptable.

A qualitative study of service user experiences of occupation in forensic mental health

This qualitative study explored occupational engagement of those detained in forensic units. Legal and institutional restrictions on occupation have implications for their health and wellbeing. Twenty-six current forensic mental health service users participated in five focus groups, which were audio-recorded, transcribed verbatim and subjected to constant comparative analysis. The participants highlighted previous occupations, current occupations and hopes. Key aspects were control over decision-making, motivation and support, generating suggestions alongside positive experiences of occupational therapy. Institutional barriers could be overcome with a dynamic balance between risk management and mental health promotion through occupation. This demands a sustained focus on occupation for everyone involved in providing care and treatment in these settings.