Forensic Mental Health Services 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.

Cognitive Interview-Based Validation of the UK Forensic Quality of Life Questionnaire – Short Version (UKFQL-SV)

ABSTRACT Quality of life for people who use forensic mental health services has been the topic of increased empirical and clinical interest in recent years. Despite this, no well-validated quality of life measure exists for use with this specific clinical population in the UK. The Forensic Quality of Life Questionnaire – Short Version (FQL-SV) is a psychometrically valid quality of life measure developed in the Netherlands and translated into English. The current study aimed to explore the validity of the English version of the FQL-SV (EFQL-SV) using a think aloud and concurrent probing cognitive interviewing procedure. Fifteen service users participated from UK-based forensic mental health services. Comprehension of the EFQL-SV was evaluated systematically. and findings indicated that the most significant difficulty for participants was the understanding of the wording of EFQL-SV items. This meant that the EFQL-SV was limited in the extent to which it measured what it purports to. A number of revisions to the EFQL-SV have been proposed but require further validation. We have titled the adapted measure the UK Forensic Quality of Life – Short Version.

The impact of misdemeanor arrests on forensic mental health services: A state-wide review of Virginia competence to stand trial evaluations.

The impact of misdemeanor arrests on forensic mental health services: A state-wide review of Virginia competence to stand trial evaluations.

Mistakes in interpersonal perceptions: Social cognition in aggressive forensic psychiatry patients.

While there is an established link between untreated psychosis and aggression, an enhanced understanding of the role of social cognition is still needed. To examine social cognitive functioning among patients in a specialist forensic mental health service who had been deemed not criminally responsible for acts of violence due to a psychotic disorder. It was hypothesised, first, that such patients would show reduced social cognitive functioning compared with healthy, nonviolent comparison participants and, second, that those who continued to be aggressive while inpatients would demonstrate significant reductions compared to the now nonaggressive group. The study samples were of 10 recently aggressive and 15 not-recently aggressive patients and 20 healthy, nonviolent comparison participants. Each completed the Toronto Empathy Questionnaire (TEQ), the Reading the Mind in the Eyes Test-Revised (RMET) and the Interpersonal Perception Task-15 (IPT-15). There was no significance between group differences on the RMET and TEQ. The patient group as a whole, however, showed significant interpersonal misperceptions, with specific misperceptions on IPT-15 deception and kinship subscales, while at the same time lacking self-awareness of their errors. Misperceptions on the IPT-15 competition subscale were unique to recently aggressive patients. Select aspects of reduced social cognitive functioning were found among not criminally responsible patients with psychosis who had committed violent acts and who continued to act aggressively while forensic inpatients. These findings enhance our understanding of the role of social cognition in predisposing toward violence and the potential importance of incorporating interventions which improve social cognition directly. We suggest also the potential for future research using virtual reality technologies in treatment.

The Impact of the COVID-19 Pandemic on Forensic Mental Health Services and Clinical Outcomes: A Longitudinal Study.

BackgroundThe COVID-19 pandemic has had a substantial impact on forensic mental health service provision and implementation. This study aimed to provide an analysis of the impact of COVID-19 related restrictions on routine outcomes within a large forensic mental health service in London, UK.MethodWe conducted a longitudinal cohort study using data collected routinely prior to the COVID-19 pandemic (April 2018–March 2020) and then stages thereafter (March 2020–March 2021; analyzed as March–May 2020, June–September 2020, October–December 2020, January–March 2021). We used causal impact models (Bayesian structural time-series) to examine the effect of COVID-19 related changes on routine outcomes related to service provision and implementation.ResultsThere was an overall increase in long-term segregation (LTS) hours during the pandemic; 140%, (95% Cl 107, 171%) during Lockdown 1; 113%, (159% Cl 127, 192%) during post-Lockdown 1; 45% (95% Cl 23, 68%) during Lockdown 2 and, finally, 90% (95% Cl 63, 113%) during Lockdown 3. The most negative outcomes were evident during Lockdown 3. Incidents of violence were significantly more frequent during Lockdown 3 than would have been predicted based on pre-pandemic data, including physical assaults to service users (206%, 95% CI 57%, 346%), non-physical assaults to service users (206%, 95% CI 53%, 339%), and self-harm (71%, 95% CI 0.4%, 135%). Use of enforced medication also increased during Lockdown 3 (317%, 95% CI 175%, 456%).ConclusionThe pandemic and its related restrictions negatively affected some service outcomes. This resulted in increased incidents of violence and increased use of restrictive interventions, beyond what would have been expected had the pandemic not occurred.

Schwartz Centre Rounds: qualitative exploration of panel members' experiences within a forensic mental health service.

Schwartz Centre Rounds (SCRs) provide a structured forum for staff from all disciplines to meet and discuss the difficult emotional and social challenges that arise in caring for patients. Research into the implementation of SCRs has shown that staff who attend report increased insight into the emotional and social aspects of care; greater understanding of the roles of their colleagues; improved teamworking and decreased feelings of isolation and stress. However, little research has explored the implementation of SCRs within forensic settings, and no research has focused solely on the experiences of panel members. Three focus groups were facilitated with participants who had participated in a SCR panel within a forensic mental health service. Semi-structured interviews were carried out, audio-recorded and subsequently transcribed. Interpretive phenomenological analysis was utilised to analyse the transcripts, and four key themes were identified. These themes were: feeling vulnerable, the importance of validation, exposure to intense emotional experiences and improved understanding and connection. We conclude that SCRs can be an emotionally challenging but rewarding experience, with the potential to enhance teamworking and general well-being. Limitations and recommendations for future research are also discussed.

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.

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study.

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

Advancing research in adult secure mental health services in England.

Forensic mental health services in high income countries are typically high cost and low volume, providing care to people with mental illness, personality disorders, learning disability and autism deemed to pose a risk to others. Research into how forensic mental health services work as a whole system is limited. Such research is urgently needed to guide policy makers and ensure that services operate effectively.

Honouring a lifetime’s work in forensic mental health services

Nurse consultant Noel McDonald won a Special Recognition Award for transforming patient experience at Belfast Health and Social Care Trust

Ten outcome measures in forensic mental health: A survey of clinician views on comprehensiveness, ease of use and relevance.

BackgroundMeasurement of outcomes in forensic mental health services is essential to ensure that these services are delivering good quality care and treatment. Instruments for outcome measurement should cover all important domains, be easy to implement in a routine clinical context and facilitate transfer of relevant information between clinicians as the patient progresses along a recovery and rehabilitation pathway.AimsWe sought the views of clinicians on 10 common instruments used as outcome measures in forensic mental health services, especially on their perceived comprehensiveness and ease of use.MethodsAn online survey was used to gather the views of clinicians from a range of professional backgrounds working in forensic mental health services in the United Kingdom. The selected instruments were identified from a previous systematic review of instruments for measuring outcomes in this context. Questions covered comprehensiveness, ease of use, patient involvement, relevance and use for progressing tracking and care planning.ResultsComplete responses were received from 229 individuals. The range of respondents either agreeing or strongly agreeing that individual instruments were comprehensive was 6–39%; easy to use 19%–69%; relevant 31%–78%; useful to measure progress 7–70%; and useful for care planning 33–81%. Respondents reported that, for each of the 10 instruments, full involvement of patients varied between 3% and 22%; partial involvement 12–45%, patients informed, but not involved 11%–28%; and patients not involved or informed 21%‐64%.ConclusionsThe Health of the Nation Outcome Scale Secure, the only instrument designed as an outcome measure, is not regarded by clinicians as useful in that respect and the majority of clinicians do not inform patients they are using it. Clinicians appear most familiar with the Historical Clinical Risk 20 (HCR‐20), which some respondents considered potentially useful as a progress measure but with limited patient involvement. Most respondents did not think that the HCR‐20 is comprehensive. There is a need for outcome measures that are comprehensive, easy to use and have adequate patient involvement in their development and rating.

The Totalising Nature of Secure and Forensic Mental Health Services in England and Wales.

This evidence-based opinion piece explores the totalising risk averse nature of secure and forensic mental health services and associated iatrogenic harms in England and Wales. Drawing on the research literature I consider the various influences, both external and internal which impact on the provision of such services and how both the therapeutic alliance and recovery potential for patients may be improved. Especial attention is paid to the deployment of restrictive practise, practitioner attitudes, the potential for non-thinking, and how these may impact on decision-making and the care and treatment of mentally disordered offenders.

Working with sex offenders with a history of sexual trauma: An Interpretative Phenomenological Analysis

Gender differences impact the work that professionals engage in with sexual offenders and victims of sexual trauma (with females often perceived as more likely to experience sexual trauma, and males as more likely to commit a sexual offence). However, there is no evidence looking at these factors in combination. This study aimed to address this gap, asking: “Are experiences of nursing staff working with sex offenders with a history of sexual trauma affected by gender differences, that is, in terms of gender of the staff member, and gender of the client they are working with?” Eight participants, (four male, four female) working within a Forensic Mental Health Service took part in semi-structured interviews. Interviews were transcribed and analysed using Interpretative Phenomenological Analysis. Five superordinate themes emerged from the data, along with a number of subordinate themes. Superordinate themes included: ‘Gender has a role’, ‘The trauma response’, ‘How we cope’, and ‘What we need’. Nursing staff working with sexual offenders with historic sexual trauma found work to be challenging both emotionally and socially. Such challenges were complicated by the gender interaction between them as professionals, and the patients who have experience of being both victims and perpetrators of sexual abuse.

Explaining the willingness of clinicians to work with patients with antisocial personality disorder using the theory of planned behaviour and emotional reactions.

Many clinicians seem to experience negative emotions towards patients with antisocial personality disorder (ASPD), resulting in the exclusion of patients in many treatment programmes. The behaviour of individuals with ASPD has a significant impact on society, which affects ASPD patients and their environment, and therefore, the exclusion from programmes is a serious concern. Relatively, little is known about why some clinicians are willing to work with ASPD patients and others are not and what factors contribute to an increase in the motivation to do so. In this study, clinicians (n = 130) working in a regular and forensic mental health service in the Netherlands completed a questionnaire based on the theory of planned behaviour (TPB) and the Feeling Word Checklist and questions about the relevant experience gained and education received. The current study confirms the limited willingness to work with ASPD patients, especially in regular mental health care. Experience working with ASPD patients, education on cluster B personality disorders and having experienced verbal and/or physical violence in clinical practice did not fully explain whether or not clinicians were motivated to provide treatment to ASPD patients. TPB appeared to predict the intention to provide psychological therapy to ASPD patients adequately. The impact of positive emotions towards ASPD patients on providing treatment appeared to be stronger than negative emotions. This study provides more insight into why so few clinicians are willing to work with ASPD patients and what may increase motivation to include this group in treatment programmes.

Development of the FORUM: a new patient and clinician reported outcome measure for forensic mental health services

ABSTRACT Forensic mental health services provide care to people in secure psychiatric hospitals and via specialised community teams. Such services are typically low volume and high cost, often highly restrictive and average duration of inpatient care prior to discharge is long. Measuring outcomes of care is important to safeguard patients and the public, monitor progress, inform treatment plans and assist in service evaluation and planning. We describe the development in England of a new outcome measure for forensic mental health services. Patient interviews and multi-stakeholder focus groups were held to elicit key concepts. Thematic analysis was used to develop an outcomes framework. Fifteen patients participated in the interviews and 48 stakeholders in the focus groups. Six domains were identified in thematic analysis: ‘about me, my quality of life, my health, my safety and risk, my life skills and my progress’. Sixty-two stakeholders participated in the first round of the Delphi process, and 49 completed round two. Eight of the top fifteen outcomes were shared between patients/carers and professionals. Based on these results, a new outcome measure, the FORensic oUtcome Measure (FORUM), was developed including both a patient reported and clinician reported measure. Further assessment of the FORUM’s use to track patients’ progress over time, and facilitate shared decision-making and care planning, is required.

Helping to embed a trauma-informed clinical model in a forensic mental health service using the seven-eyed model of supervision

In this article we explore how a forensic mental health service incorporated trauma-informed principles into the seven-eyed model of supervision (Hawkins & Shohet, 2012) to help embed our new clinical model and improve the quality of supervision across the service.

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.

Gender Differences in Substance Abuse History and Offending Behavior: A Multicentre Study in Dutch Forensic Psychiatry

ABSTRACT Substance abuse is an important risk factor for offending, but is mostly studied in males. The aim of this multicentre study is to gain insight into possible gender differences in substance abuse history and offending behavior in forensic psychiatric patients. Files were analyzed of 275 women and 275 matched men who have been admitted between 1984 and 2014 to one of four Dutch gender-mixed forensic hospitals. Risk assessment ratings were related to registered violent incidents during treatment for both women and men and to official recidivism data after discharge for a subgroup of 78 women. Substance abuse history was coded as a risk factor for more than half of the women (56.7%), but significantly more often for men (68.4%). Men were more often diagnosed with substance dependence and more frequently committed the index-offense whilst intoxicated. Prediction of violent incidents during treatment was more accurate for men. A history of substance abuse was not a significant predictor for recidivism after discharge in the subgroup women. It is concluded that there are gender differences in substance abuse history and that the relationship with offending behavior seems stronger for men. These differences have implications for substance use treatment in forensic mental health services.

Tū Tahanga: A Qualitative Descriptive Study of a Culturally Adapted Violence Prevention Programme in a Forensic Mental Health Service

There is growing evidence that culturally adapted, evidence-based, violence prevention programmes can have benefits for people in correctional and forensic mental health services. Adding to this evidence is crucial, given the over-representation of Indigenous people and ethnic minorities in such services. This qualitative descriptive study describes Tū Tahanga, which combines the ManAlive violence prevention programme, with Māori (Indigenous people of Aotearoa/New Zealand) cultural concepts. This was developed for Māori service users in a forensic mental health service. Content analysis was undertaken through interviews with participants in the group (N = 11). Core aspects of ManAlive were maintained. These aspects coexist with cultural concepts of a specific healing space, a holistic Māori model of health, and the creation of family like supportive relationships reinforced by living in the same facility. This description lays a platform for future evaluative research to determine the impact of the programme on reducing violent offending.