Forensic Mental Health Services Research Articles

Time use of patients in a secure forensic hospital: A mixed methods study.

Forensic mental health services balance recovery-focussed therapy with risk management, which may limit opportunities for participation in meaningful occupation. Previous research describes forensic patients in secure settings participating mainly in passive leisure and sleep. This study aimed to use quantitative and qualitative evidence to investigate how patients in the sub-acute and rehabilitation units of an Australian forensic hospital perceive and use their time and to discuss how the findings compare with the previous study within the organisation, published in 2004. An explanatory sequential mixed methods design was used with convenience sampling of patients and purposive sampling of staff. Patients completed time use diaries followed by semi-structured interviews. Staff perceptions were obtained via survey. Seven male patients with a diagnosis of schizophrenia and five staff members (three occupational therapists and two nurses) participated. Time use diaries indicated patients spent most time in personal care, passive recreation, and leisure activities. Qualitative data illustrated patient time use was influenced by the individualised meaningfulness of activities. Patients drew meaning from past roles, personal interests/needs, and their goals for recovery. While patients had some choice over how time is spent and with whom they chose to engage, external factors such as staff/program availability prevented their having full control. Staff provided additional perspectives on the links between time use and recovery, identifying enablers and barriers to meaningful time use. Patient time use has not changed significantly when compared to past research, although perceptions of time use are more future and recovery-focussed. The amount of time recorded in activities typically associated with recovery does not necessarily capture the quality and benefit of that time use. Patient participation continues to be influenced by broader systems.

Identifying core mental health services required for adult justice-involved populations in Australia: a Delphi study

This study aimed to define required forensic mental health service types in Australia. A staged Delphi process was used, including: (1) reference group consultation to establish a set of core forensic mental health service types; (2) Delphi survey to seek consensus on identified service types and definitions among forensic mental health stakeholders in Australia; and (3) amendment of service definitions in response to survey feedback. Nine forensic mental health service types were identified. Consensus (>80% agreement) was achieved among Delphi respondents that all services were core components of an ideal forensic mental health system. These included forensic bed-based (acute, sub-acute, non-acute, non-acute community), forensic community, outreach, prison and court liaison services. The high levels of agreement on service types are notable considering legislative differences impacting on design and operation of services across jurisdictions. The findings could contribute to the evidence base required for needs-based planning of forensic mental health services.

The living experience of First Nations Peoples and Forensic Mental Health systems: listening to the deep stories behind the numbers

While First Nations Peoples in Australia experience high rates of criminal justice contact, there is limited research on their experiences of the forensic mental health system. This study aims to develop new understandings of how First Nations Peoples experience and understand the forensic mental health system in NSW. Interviews were conducted with ten First Nations Peoples in contact with the forensic mental health system, including forensic patients and their family members. Participants described challenging life experiences prior to their contact with the forensic mental health system, with community services often failing to respond to their mental health needs. While participants reported some positive experiences with the forensic mental health system, they ultimately described an urgent need for culturally appropriate programs that facilitate connections to family and Community. Forensic mental health services should be co-designed alongside First Nations Peoples and communities to improve outcomes and avoid re-traumatisation through contact with services.

“Prison Life Can Make You Go Crazy”: Insights Into the Situation for People With a Mental Illness in the Malawi Prison System

Little is known with regard to due process and forensic assessment capacities in Africa, where over one million are deprived of their liberty on any given day. A rapid situation assessment explored multi-stakeholder perspectives regarding the situation of people with a mental illness in the Malawi prison system. In-depth interviews were conducted with 10 regional professional stakeholders, 18 former prisoners, and five prison staff from two maximum-security prisons. Reflexive thematic analysis yielded five themes; occurrence of mental illness among people living in prison; prison environment exacerbating harm and levels of mental illness; security responses to the presence of psychiatric disorders; availability and coverage of specialist psychiatric and psychological care; and diversion, other non-custodial measures and continuity of care on release. Narratives highlight the substantial causal impact of the prison environment in amplifying existing and new mental illness, vulnerability and exploitation of people with a mental disorder. Malawi prisons are hampered by lack of specialist forensic capacity nationally; centralized mental health surveillance system; and insufficient skilled staff to conduct evidence-based screening and care. Security operations implement the use of pharmacological and physical restraint measures at times. Faith-based organizations play an important role in providing psychological and spiritual support. Release and reintegration require family involvement. A cross departmental intersectoral partnership response spanning government ministries, key civil society organizations, the Malawi Prison Inspectorate and Malawi Human Rights Commission is warranted. Recommendations include alleviation of prison congestion, prison staff capacity building and investment in forensic mental health services with adequate geographic coverage.

Motiv8: a study protocol for a cluster-randomised feasibility trial of a weight management intervention for adults with severe mental illness in secure forensic services

IntroductionPeople with severe mental illness have physical comorbidities which result in significant reductions in quality of life and premature mortality. Effective interventions are required that are suitable for people in secure forensic mental health services. We conducted pilot work of a multidisciplinary weight management intervention (Motiv8) which showed improvements in physical and mental health and high levels of satisfaction. We aim to test the feasibility of Motiv8 under cluster randomised conditions, with an aim to investigate the acceptability, feasibility and potential effectiveness of this intervention to supplement standard secure care.Methods and analysisA randomised waitlist-controlled feasibility trial of a lifestyle intervention (Motiv8) + TAU compared with TAU (+ Motiv8 waitlist) for adults on secure mental health units will be conducted. Thirty-two people (4 cohorts) will be recruited from secure services in Greater Manchester Mental Health NHS Foundation Trust. Participants will be randomly allocated to Motiv8 or TAU + Motiv8 waitlist. All participants will receive Motiv8 during the trial. Assessor-blinded physical/mental health and lifestyle assessments will be conducted at baseline, 10 weeks (post-intervention/waitlist), and after 12 weeks (post-waitlist intervention/follow-up). Motiv8 is a multidisciplinary intervention including exercise sessions, cooking/nutrition classes, physical health education, psychology sessions, sleep hygiene, peer support and medication review by pharmacy. A nested qualitative study will be conducted with a subsample of participants (n = 10) to explore their experiences of taking part. The analysis will focus on feasibility outcomes and tabulated success indicators of the study (e.g. Recruitment rates, retention rates, follow-up retention and response rates, attendance at sessions, the experience of involvement in the trial and delivery of the intervention, assessment of safety, development of a manualised intervention). Thematic analysis will be conducted through qualitative interviews. The analysis will aim to inform the development of a definitive trial.Ethics and disseminationThe trial has been granted ethical approval from the NHS Health Research Authority and adopted onto the UK Clinical Research Network Portfolio. Findings will be disseminated via peer-reviewed publications, professional and public networks, conferences and clinical services.Trial registrationISRCTN13539285.

What are the key influences and challenges around weight management faced by patients in UK adult secure mental health settings? A focused ethnographic approach

ObjectivesExcess weight is highly prevalent in secure (forensic) mental health services and impacts negatively on patients’ physical and mental health. This study sought to identify the key influences and challenges...

Trauma-Informed Care Training in Forensic Mental Health Services: A Scoping Review

Within forensic populations, exposure to traumatic experiences is high. These experiences are associated with multiple mental and physical health problems later in life. Forensic services would therefore ideally adopt a trauma-informed approach. The aim of this scoping review is to identify trauma-informed training or education for staff within forensic mental health care. A database search of English or Dutch language articles from PubMed, PsycINFO, Embase, Scopus and Web of Science was performed. Researchers reviewed 6,386 articles and nine were included for final analysis, all in justice-involved youth populations. Results show that training in trauma-informed care may facilitate the relationship between staff members and residents and create safer treatment units. Besides this, a reduction in post-traumatic stress symptoms and greater clinical improvement in depression, anxiety, hope and optimism among justice-involved youth was noted. Trauma-informed staff training may also lead to a decrease in incidents taking place as well as a decrease in use of restraints and seclusion.

Data resource profile of an online database system for forensic mental health services

This paper introduces a forensic psychiatry database established in Japan and discusses its significance and future issues. The purpose of this Database, created under the Medical Treatment and Supervision Act (MTSA) Database Project, is to improve the quality of forensic psychiatry treatment. It can collect monthly data on “basic information,” “Orders and hospitalizations under the MTSA,” “Treatment process,” “Criminal and medical treatment history,” and “problematic behavior in the unit.” The online system has accumulated data on more than 8,000 items in 24 broad categories. Medical data are exported from the medical care assisting system of 32 designated inpatient facilities in XML format and then saved on USB memory sticks. The files are imported into the Database system client, which sends the data to the Database server via a virtual private network. This system minimizes errors and efficiently imports patient data. However, there is a limitation that it is difficult to set items that need to be analyzed to solve everyday clinical problems into the database system because they tend to change over time. By evaluating the effectiveness of the Database, and collecting appropriate data, it is expected to disseminate a wide range of knowledge that will contribute to the future development of mental health and welfare care.

An examination of service user satisfaction in forensic mental health settings.

High levels of service user satisfaction are viewed as a reliable indicator of a service providing good care and treatment. There has been limited research looking into levels of satisfaction in forensic mental health settings with most work focused on staff satisfaction in these settings. This study examined service users' levels of satisfaction with a forensic mental health service in the United Kingdom. The service covered two sites; one a purpose-built secure unit and the other based in an old cottage hospital. Thirty-nine in-patients completed a 60-item validated forensic satisfaction scale. The scale measured seven domains of satisfaction as well as reporting an overall satisfaction score. The results indicated the service users were reasonably satisfied with the care and treatment they received. The domains of rehabilitation, safety, staff interaction and overall care showed the highest level of satisfaction. The high rehabilitation satisfaction score demonstrated the importance of meaningful activities for users accessing forensic services and may have been influenced by the security measures on the wards. The high safety domain score indicated respondents felt safe and secure within the wards and were likely to be influenced by positive interpersonal interactions. Good staff interaction was also an important factor in helping service users feel safe on the wards. These interactions are likely to be associated with longer periods of admission in secure services allowing therapeutic relationships to develop. Financial advice/support was the one domain that recorded negative satisfaction levels. Financial literacy training may help develop money management skills.

Occupational therapy with patients in forensic solitary confinement: A qualitative study.

Occupational therapists work with forensic mental health patients in solitary confinement to counter impacts of mental illness and occupational deprivation, to promote well-being and support transition to less restricted environments. There is little literature describing occupational therapy in this context. This study aimed to explore and describe the work, context and professional reasoning of occupational therapists working in solitary confinement settings within a large forensic mental health service in Victoria, Australia. A qualitative design used semi-structured interviews with 11 occupational therapists and reflexive thematic analysis. Three central organising themes, it's all about risk, the work we do and why we do what we do, provided rich description of the context and work of occupational therapists in solitary confinement settings, including approaches used to engage patients in occupation and how the Model of Human Occupation and recovery principles informed their professional reasoning. Despite the setting restrictions, participants engaged in core elements of the occupational therapy practice process and described creative work that offered patients choice and meaningful occupation. They described occupational enrichment to address occupational deprivation and create opportunities for change within the highly restrictive and risk-focussed environment of solitary confinement. Assessment was mainly unstructured, and the need for better evaluation of therapy outcomes acknowledged. Goal setting often focussed on immediate needs. Working in a risk-focussed environment influenced participants' professional reasoning and work with patients, and while they advocated for occupational opportunities for patients, frustration was experienced in response to limits to occupational therapy involvement in risk assessment. The findings address a gap in the literature about the work of occupational therapists in forensic solitary confinement. Though participants' reasoning was informed by occupational and recovery principles, and they described working in occupation-based ways, they did not always articulate explicit connections between theory and practice.

Forensic mental health in Kuwait: filling the gaps

The case of M’Naghten (1843) laid out the insanity defence test for the British legal system. Later, many countries basing their criminal legislation on the British common law system, including the Criminal Act of Kuwait, adopted the test. The Act forms the basis for forensic psychiatric assessments. Several countries amended their criminal laws to provide a better balance between public safety and human rights protection. However, the Criminal Act of Kuwait remains unchanged for offenders with mental illness since its enactment in the early 1960s, with several gaps concerning the detention mechanisms and the discharge of such offenders. However the Kuwait Mental Health Law (2019) eventually filled these gaps. This paper describes the function of forensic mental health services in Kuwait, discusses and compares the Criminal Act of Kuwait with other nations’ criminal laws and describes the forensic section of the Kuwait Mental Health Law (2019).

A Nominal Group Technique to finalise Safewards Secure model and interventions for forensic mental health services

Accessible SummaryWhat is known on the subject? Safewards was developed for acute mental health units, and while could be effective in forensic mental health services, there are some gaps in the model for such services, where factors including offending behaviour and longer term care can have an influence. What this paper adds to existing knowledge? The importance of acknowledging and addressing responses related to offending behaviour in forensic mental health settings, while also understanding the vulnerability of the consumer group and responsibilities to the maintenance of professional boundaries. Enhancing collaboration with consumers/families/carers/supporters is important in a forensic mental health setting, and an important element of Safewards Secure. What are the implications for practice? This study completes the development of Safewards Secure, designed to foster collaboration, address issues pertinent to forensic mental health settings to enhance implementation and acceptance of the model and reduce conflict and containment. AbstractIntroductionSafewards is a model developed for acute mental health settings designed to reduce conflict and containment; however, it requires adaptation to forensic mental health settings.AimTo develop the Safewards Secure model, a model to assist forensic mental health services to reduce conflict and containment.MethodA literature review was conducted to elicit possible modifiers and adjustments to the interventions. A Nominal Group Technique was then used to engage forensic mental health experts who had experience implementing Safewards (n = 12) to seek feedback about the suggestions and reach consensus on the Safewards Secure model and interventions. Data were thematically analysed.ResultsExperts reached consensus on all suggestions, however, did recommend minor additions and modifications. Two themes were also interpreted: Safewards Secure is just as much for staff as it is for consumers, and the proposed additions encourage more meaningful staff to consumer collaboration.DiscussionThis study identified key challenges experienced by nurses working in forensic mental health settings, however, these challenges were not seen as insurmountable. The Safewards Secure model offers prompts and suggestions to encourage reflection, collaboration and a humanistic approach to care in forensic mental health settings.Implications for PracticeAddressing reactions to offending behaviour and encouraging more collaboration might assist in ensuring a more person‐centred approach to forensic mental health nursing care.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility.

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Do forensic mental health services have an ethical duty towards victims of mentally disordered offenders?

ABSTRACT Despite important changes in the rights of victims of crime and their role in influencing public policy across most jurisdictions, victims of mentally disordered offenders are often neglected in public discourse. They are also neglected in clinical discourse by forensic practitioners who are responsible for the care and treatment of mentally disordered offenders. In England, as in other countries, this duty is outsourced to public sector agencies for the most part. This review sets out to understand what has been written about ethical obligations of forensic practitioners towards victims. An examination of literature on ethical dilemmas commonly encountered in forensic mental health services has found that most of the existing literature focuses on issues such as the dual obligation nature of the specialty and the difficulties of promoting autonomy in long-term incarceration, with relatively little written about ethical obligations towards the victims of our patients. Some of the ethical and clinical arguments for including victims in our thinking are described, considering the Principlist approach of biomedical ethics, as well as other approaches including relational and communitarian ethics. Some implications for practice are considered.

Procedural justice and forensic mental health: An introduction and future directions.

This article advocates for integrating procedural justice principles into forensic mental health services to enhance patient engagement and autonomy. Procedural justice, broadly defined as fair decision-making processes, is introduced and key principles including voice, neutrality, respect and trustworthiness are described. Evidence suggestive of positive outcomes following procedural justice experiences, such as improved satisfaction, collaboration and reduced perceptions of coercion is outlined. Practical applications are suggested, including staff training and reflective practices using procedural justice principles. The article then calls for further research to explore patients' and staff members' experiences of procedural justice in forensic settings, develop measurement tools, undertake intervention studies and establish causal links between procedural justice and outcomes important for forensic patients.

Excellence in forensic psychiatry services: international survey of qualities and correlates.

Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development. To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security. A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire. Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score. Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BackgroundPatients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the ‘triply troubled’. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB. MethodsA three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB. ResultsA four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression. ConclusionsThe present study helps disentangle the heterogeneity of the ‘triply troubled’ patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis

Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered. In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716. We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%). Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support. Wellcome Trust.

Peer Support-Led Interventions in Forensic Settings: Listening to Service Users and Peer Support worker’ Perceptions and Experiences

ABSTRACT Repeatedly, peer support (PS) research in mental health settings has indicated the influential impact of PS on recovery outcomes, including community reintegration and overall quality of life. Despite these findings, and the bolstering of PS in UK healthcare policy, PS remains underdeveloped in UK mental health settings. This is particularly pronounced in forensic mental health settings where the development of PS has remained heavily restricted by application difficulties in secure care models. The current study aims to provide one of the first in-depth explorations of PS experiences for both service users (SUs) and peer support workers (PSWs) in UK forensic mental health services. Semi-structured interviews were conducted with 13 participants (ten SUs, three PSWs) and analyzed using thematic analysis. Four primary themes were identified detailing the experiences and challenges of forensic-based PS: Experiences of PS from SU perspective; Experiences of PS from PSW perspective; Contrasting care: Addressing the “Us and them” divide, and Further service development. Recommendations identified for progressing PS center on integration improvements, increasing the variety of peer-led interventions, and incorporating PS’s “flexible” nature into traditional models of care. Further action is needed to develop and embed PS in forensic care, including guidance for the development of strategies and policy, and direction for future research.

A Comprehensive Framework to Advance Equity, Diversity, and Inclusion in a Forensic Service.

Minority and Indigenous populations have disproportionate representation within forensic mental health services. Social determinants of health and systemic discrimination have contributed to the difficulties these populations have in accessing care, as well as significant differences in care trajectories. In addition, staffing and structural equity, diversity, and inclusion (EDI) challenges permeate forensic systems as in other health care settings. There is little literature to guide forensic mental health services in how best to provide equitable, diverse, and inclusive practices for patients, families, and staff. The forensic service at a major urban center in the Canadian province of Ontario has adapted an EDI framework to describe the processes employed to organize and integrate EDI principles and initiatives within a culture of learning and continuous improvement. This Forensic EDI Framework is composed of six domains: Organizational Commitment, Staff/Workforce Competencies, Service Access and Delivery, Promoting Responsiveness, Community Outreach, and Data Collection. Initiatives within each of these domains form the foundation of a sustainable platform for forensic service EDI practices that will promote lasting change.