Forensic Mental Health Services Research Articles

Identifying studies examining the validity of instruments for use as outcome measures in child and adolescent forensic mental health services: a systematic review.

Outcome measurement in child and adolescent forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aimed to identify studies which validate structured instruments available for use as outcome measures in the child and adolescent forensic mental health service cohort and assess the quality of these studies. A systematic review was conducted following PRISMA guidelines. Studies were identified by searching six online databases in November 2023. The quality and risk of bias of each study meeting inclusion criteria was independently assessed by two authors using the Crowe Critical Appraisal Tool. Results were synthesised narratively. A total of eight studies were identified which met inclusion criteria. These looked at six instruments which primarily focused on outcome measures in the areas of treatment motivation, level of functioning, psychiatric symptoms, care needs and response to social situations. Papers scored between 17/40 and 30/40 on the Crowe Critical Appraisal Tool. Studies were rated as low (n = 1), moderate (n = 6), high (n = 1) or very high quality (n = 0). Despite the large number of structured instruments potentially available, evidence for their use as outcome measures in child and adolescent forensic mental health services is limited. Future research should aim to validate current structured instruments for use in the forensic child and adolescent setting, with consideration of whether new instruments should be developed specifically for this group. Such instruments should be developed with both young people as service users and professionals who will be utilising the instrument in mind.

A systematic review of evaluative instruments for the purpose of monitoring forensic patient recovery and outcomes

ABSTRACT Ideally, evidence-based patient outcomes would be collected on a 6-monthly basis, allowing accurate measurement of treatment progress. This would encourage research and subsequent development of forensic mental health services. Lack of standardised routine outcome collection within Scotland may be acting as a barrier to this. The Royal College of Psychiatrists recommends that evidence-based clinical and patient-reported data should be collected; however, no specific measures are recommended. COnsensus-based Standards for health Measurement INstruments (COSMIN) guidelines for systematic reviews of outcome measures were followed and their Risk of Bias tool used to evaluate the quality of studies. Instrument content validity, for the purposes of measuring forensic patient recovery, was analysed separately through review of articles relating to instrument development and user feedback. From four evaluative instruments selected by predefined criteria, only Structured Assessment of Protective Factors for violence risk (SAPROF) and Instrument for Forensic Treatment Evaluation (IFTE) possessed the core psychometric properties of a useful outcome measure. These two instruments can therefore be recommended for the purpose of monitoring forensic patient recovery, with SAPROF being the more feasible option. HCR-20 and HoNOS-secure were found to lack content validity for this purpose. Additional psychometric studies for SAPROF are recommended.

Racial trauma as an unlaid ghost of empire

The persistence of racism is explored intersectionally, through a personal narrative or herstory, which includes extracts of childhood, professional experiences within forensic mental health services, and in relation to group analytic roles. Reflections are underpinned by two theories; Freud’s seminal theory of trauma as an unlaid ghost and Foulkes’s group analytic premise that human beings are permeated to the core with social context, including that which is transgenerationally transmitted. Thus, it is proposed that racial trauma may be thought about as an unlaid ghost of Empire, the dynamics of which are continuously re-enacted during interactions between people and, it is suggested, can be understood as internal working models laid down at an unconscious level and arguably integrated within our attachment systems. Hence, the emergence of racist attitudes and behaviour during intense attachment experiences, whether personal, group or societal in origin.

Offering family intervention for psychosis in a forensic service; a quality improvement project

There is strong evidence supporting the use of family intervention (FI) as standard practice for all families of service users with psychosis (NICE, 2014). In practice, most mental health services have been found to fall short of this ideal, most commonly due to limitations in resources such as dedicated time and training (Ince et al., 2016). Other barriers named in this systematic review include staff lack of confidence in skills, undervaluing the model of therapy and dominance of the medical model of treatment. This paper details a quality improvement project examining the provision and barriers to provision of FI in an NHS forensic mental health service consisting of medium secure wards, low secure wards and a community team. Information was gathered from a range of sources including electronic files, questionnaires and interviews. Approximately a third of the client group (n=208) were found to be eligible for FI on the basis of diagnosis and family contact, but records indicated that FI had only been considered for a third of those eligible. Barriers to delivery of FI in the service are identified alongside recommendations for service improvement. Whilst these are specific to the service studied, there are parallels with findings from other research, and the recommendations may be transferable to other services

Relationships between adverse childhood experiences, attachment, resilience, psychological distress and trauma among forensic mental health populations

ABSTRACT There has been an association between adverse childhood experiences (ACEs), attachment style and resilience with later life psychological distress, yet this area remains under-researched among forensic mental health populations. The current study aimed to explore predictive relationships between ACEs, attachment and resilience and later-life psychological distress and trauma in a sample with a history of forensic mental health service use. A total of 128 participants completed six questionnaires relating to these factors: The Adverse Childhood Experiences International Questionnaire (ACE-IQ); the Vulnerable Attachment Scale Questionnaire (VASQ); the Child and Youth Resilience Measure (CYRM); the Resilience Research Centre Adult Resilience Measure (RRC-ARM); the Clinical Outcomes in Routine Evaluation-10 (CORE-10); and the International Trauma Questionnaire (ITQ). ACEs were found to be highly prevalent and significant correlations were found between lower levels of adult resilience and insecure attachment, and increased psychological distress and trauma symptoms. Attachment style was found to mediate some of these relationships. The findings support a model in which higher ACEs may lead to insecure attachment style and low resilience in the forensic mental health population, thereby resulting in higher levels of later life psychological distress and trauma. Attachment and resilience may be important factors to consider for preventative and reactive interventions within forensic mental health care.

Private and Public Sector Differences in Adverse Incidents and Restrictive Practices: Factors That Predicted Service Sector in a National Sample of Forensic Psychiatric Inpatients

Forensic mental health services play a key role in the diversion, treatment, rehabilitation, and supervision of offenders with mental health problems in Europe. Private sector providers are increasingly commissioned to provide secure care for service users. Questions have been raised about the effectiveness of the private sector providers. A sample of 229 patients from low, and medium secure psychiatric services in the United Kingdom was analyzed to determine differences in restrictive practices, adverse service user incidents, and service user characteristics between service users admitted to private sector or publicly funded hospitals. Service users with a diagnosis of a personality disorder, and those who had multiple psychiatric diagnoses were disproportionately placed in the private sector. Greater prevalence of seclusion, physical restraint, verbal aggression toward staff, physical violence toward staff and other service users, property damage, and self-harm were observed in private sector service users. Further attention is warranted around the decision-making processes that allocate people to private versus publicly funded care, potential sources of bias in admission characteristics should be taken into account when interpreting poorer clinical outcomes in the private sector.

Adverse childhood experiences in a london-based forensic CAMHS population

Youth crime is a serious political and social issue, impacting significantly on the young person’s identity, and their community and societal integration and development (Rutter, 2010). Recently, London has experienced some of the highest recorded rates of crimes committed by youth resulting in many custodial settings being at full capacity. Significant attention has been attributed to formulating why some young people become involved in criminal behaviour and many recognise the role of early adversity, which may act as a vulnerability or precipitating factor for some. The association between Adverse Childhood Experiences (ACEs) and youth crime has been researched in many countries and helps to formulate why some young people may engage in crime. This paper investigates the ACEs in a sample of 164 London-based youth who were referred to Forensic Child and Mental Health Service (FCAMHS), by local services. Results indicated that all young people referred had experienced at least one ACE. Those presenting with eight or more ACEs were referred for engaging in serious community violence. While this does not predict or show causation, it is helpful in considering the level of vulnerability and adversity in this cohort of young people. These findings have important implications in the assessment and management of these young people, who may be seen as both victims of adversity and perpetrators of possible crime. Further, these findings can help promote a balanced way of thinking about the whole young person, not just the part that may have committed a crime.

Change in Quality of Life After Moving a National Forensic Mental Health Service: A Dundrum Forensic Redevelopment Evaluation Study (D-FOREST)

Change in Quality of Life After Moving a National Forensic Mental Health Service: A Dundrum Forensic Redevelopment Evaluation Study (D-FOREST)

Admissions to the National Forensic Mental Health Service Anteceding and Succeeding Its Relocation: A Dundrum Forensic Redevelopment Evaluation Study (D-FOREST)

Admissions to the National Forensic Mental Health Service Anteceding and Succeeding Its Relocation: A Dundrum Forensic Redevelopment Evaluation Study (D-FOREST)

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.

Investigating the impact of the COVID-19 pandemic on recovery colleges: multi-site qualitative study.

During the COVID-19 pandemic, mental health problems increased as access to mental health services reduced. Recovery colleges are recovery-focused adult education initiatives delivered by people with professional and lived mental health expertise. Designed to be collaborative and inclusive, they were uniquely positioned to support people experiencing mental health problems during the pandemic. There is limited research exploring the lasting impacts of the pandemic on recovery college operation and delivery to students. To ascertain how the COVID-19 pandemic changed recovery college operation in England. We coproduced a qualitative interview study of recovery college managers across the UK. Academics and co-researchers with lived mental health experience collaborated on conducting interviews and analysing data, using a collaborative thematic framework analysis. Thirty-one managers participated. Five themes were identified: complex organisational relationships, changed ways of working, navigating the rapid transition to digital delivery, responding to isolation and changes to accessibility. Two key pandemic-related changes to recovery college operation were highlighted: their use as accessible services that relieve pressure on mental health services through hybrid face-to-face and digital course delivery, and the development of digitally delivered courses for individuals with mental health needs. The pandemic either led to or accelerated developments in recovery college operation, leading to a positioning of recovery colleges as a preventative service with wider accessibility to people with mental health problems, people under the care of forensic mental health services and mental healthcare staff. These benefits are strengthened by relationships with partner organisations and autonomy from statutory healthcare infrastructures.

Risk and protective factors in risk assessment: Predicting inpatient aggression in adult males detained in a forensic mental health setting.

Structured clinical risk assessments represent a preferred means of assessing levels of aggression risk at different times and in different individuals. Increasing attention has been given to capturing protective factors, with sound risk assessment critical to high-secure forensic mental health care. The aim was to assess the predictive value of the HCR-20v3 for aggression risk and the long-term care pilot version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population and to determine the incremental value of protective over risk factors.Participants were adult males detained in a high secure forensic mental health service, with a primary diagnosis of schizophrenia and/or personality disorder. The focus was on examining hospital based aggression (self- and other-directed) at two time points; up to 6 months (T1) and between 7 and 12 months (T2).The HCR-20V3 and SAPROF-LC-pilot demonstrated good predictive validity but with variability across subscales and aggression types/periods. Historical factors of the HCR-20V3 and External factors of the SAPROF-LC-pilot failed to predict, aside from a medium effect at T1 for verbal aggression and self-harm, for Historical factors. There was evidence for protective factors adding to prediction over risk factors alone, with the integration of protective and risk factors into a risk judgement particularly helpful in improving prediction accuracy.Protective factors contributed to risk estimates and particularly if integrated with risk factors. Combining risk and protective factors has clear predictive advantages, ensuring that protective factors are not supplementary but important to the aggression assessment process.

“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.