Forensic Mental Health Settings Research Articles

Clinician Perceptions of Implementing the Cultural Formulation Interview on a Mixed Forensic Unit.

The use of the Cultural Formulation Interview (CFI), a 16-item, semistructured, patient cultural assessment, in a forensic mental health setting has not been examined. Using a mixed-methods approach, we performed a pilot test of the CFI in an inpatient service that treats both forensic and nonforensic adult patients. Clinicians' attitudes toward adoption of the CFI was assessed quantitatively with the Evidence-Based Practices Attitudes Scale, which is used to measure provider attitudes toward adopting new treatments, and qualitatively with a semistructured interview. Assessments occurred up to five times to analyze changes with increasing CFI use. In the quantitative measures we observed a general openness to implementing the CFI throughout the implementation period. Compared with clinicians on civil units, forensic clinicians indicated they were less likely to implement the CFI over time if it were required rather than voluntary. Interviews with clinicians revealed concerns about the skills, ability, and confidence needed to implement the CFI, external requirements, and the ease of integrating the CFI into their practice. Based on our findings, forensic units could encourage CFI use after the clinician has determined that the patient is clinically stable, rather than at admission. Units could also incorporate information obtained from the CFI into current documentation to reduce administrative burden.

‘My journey through the system’: a grounded theory of service user-perceived experiences of recovery in forensic mental health services

ABSTRACTThe ‘Recovery Approach’ is widely regarded as the guiding principle for mental health service delivery in the UK. Forensic services face unique challenges in applying this approach. Numerous studies have explored themes associated with recovery in these settings but it is unclear how themes relate to each other. This study set out to build a theoretical model of service user experiences of recovery in forensic mental health settings. Semi-structured interviews were conducted with 16 service users about their recovery. Grounded Theory methodology, with a constructivist epistemology, was used to analyse the data. A cyclical model was developed, with five-core recovery processes that inter-related; these were the environment, connectedness, hope for the future, who I am and empowerment. These occurred in three phases of 1) feeling safe and secure, 2) moving forward, and 3) empowerment. These processes were encompassed by two additional themes of arriving at the hospital and changes over time. This study is the first to provide a clear model of service user experiences of recovery in this setting.

Training needs analysis of nurses caring for individuals an intellectual disability and or autism spectrum disorder in a forensic service

Purpose Examining the education and training needs of forensic nurses is paramount as services move from the older institutions to new care settings. The purpose of this study was to identify Irish Forensic nurses perceived deficits in their knowledge and skills to assist them to provide effective seamless care for individuals with an intellectual disability within their forensic mental health service, so that appropriate training could be provided. Design/methodology/approach Training needs analysis (TNA) procedures are used as a way of establishing the continuing processional development of staff, as they seek to identify the gaps between the knowledge and skills of an individual and the need for further training. A training needs tool developed by Hicks and Hennessy (2011) was used and completed by nurses working in an Irish forensic mental health service. A total of 140 surveys were circulated and 74 were completed (51 per cent response). Findings The top priority training needs identified were for additional training in research and audit and in the use of technology. Other self-identified training needs included additional training in behavioural management for challenging behaviour, understanding mental health and intellectual disability and dual diagnosis, training in enhancing communication skills and how to work with patients who have an intellectual disability patients specific training on autistic spectrum disorders and a guide and template for advance individual care planning and for caring for the physical health needs and promoting the physical health needs of these patients. Originality/value Despite there being a vast range of training issues identified, the majority of nurses appear to have a clear idea of their training needs to ensure the provision of seamless care for individuals with an intellectual disability within a forensic mental health setting. This TNA has identified the specific needs of nursing staff working at different positions across the interface of intellectual disability and forensic mental health care.

The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff.

Inpatient aggression on mental health wards is common and staff-patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n=85 inpatients and n=65 nurses were recruited from adult, low- and medium-secure wards of a secure forensic mental health service. Participants completed validated self-report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3-month follow-up period were extracted from clinical records. Dyadic nurse-patient relationships were anticomplementary. Patients' self-reported anger and staff-rated hostile interpersonal style were significantly positively correlated; staff self-reported anger and patient-rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.

Assessing firesetters with intellectual disabilities

PurposePeople with intellectual disabilities who set fires are a heterogeneous and clinically complex group who present significant challenges to the wider community and to forensic practitioners working in forensic mental health and correctional settings. There is little available in the literature to support professionals when considering assessment and formulation for clients exhibiting these perturbing behaviours. The paper aims to discuss this issue.Design/methodology/approachIn this paper the materials available to assist forensic practitioners in considering assessment and formulation of people with intellectual disabilities who set fires are described and outlined.FindingsAn assessment scheme is proposed for organising information from a variety of sources to assist professionals in understanding the nature of risks and clinical needs of firesetters with intellectual disabilities. A newly revised risk assessment measure designed for this population is provided.Practical implicationsForensic practitioners are provided with a framework and tools to assist with their assessment and formulation of firesetters with intellectual disabilities.Originality/valueThis is the first time a newly revised risk assessment for firesetting behaviour by people with intellectual disabilities has been presented.

Barriers and facilitators to the implementation of individual placement and support (IPS) for patients with offending histories in the community: The United Kingdom experience

Introduction We aimed to identify the barriers and facilitators to the implementation of a high fidelity individual placement and support service in a community forensic mental health setting. Method In-depth interviews were conducted with clinical staff ( n = 11), patients ( n = 3), and employers ( n = 5) to examine barriers and facilitators to implementation of a high fidelity individual placement and support service. Data was analysed using thematic analysis, and themes were mapped onto individual placement and support fidelity criteria. Results Barriers cited included competing interests between employment support and psychological therapies, perceptions of patients’ readiness for work, and concerns about the impact of returning to work on welfare benefits. Facilitators of implementation included clear communication of the benefits of individual placement and support, inter-disciplinary collaboration, and positive attitudes towards the support offered by the individual placement and support programme among stakeholders. Offences, rather than mental health history, were seen as a key issue from employers’ perspectives. Employers regarded disclosure of offending or mental health history as important to developing trust and to gauging their own capacity to offer support. Conclusions Implementation of individual placement and support in a community mental health forensic setting is complex and requires robust planning. Future studies should address the barriers identified, and adaptations to the individual placement and support model are needed to address difficulties encountered in forensic settings.

A Systematic Review on Implementing Education and Training on Trauma-Informed Care to Nurses in Forensic Mental Health Settings.

Engaging in trauma-informed approaches in nonforensic mental health settings improves therapeutic relationships, promotes healing, promotes posttraumatic growth, improves staff well-being, and fosters hope and empowerment, yet little is known of its influences in forensic settings. This literature review explores trauma-informed education and its training implications for nurses working in forensic mental health. Using a range of electronic databases, a systematic search of literature was carried out focusing on trauma-informed practice in adult forensic mental health settings. Before searching, predefined inclusion and exclusion criteria were agreed. After duplication removal, abstract review, and full screening, nine articles met review criteria for inclusion. A thematic analysis of the literature identified two key themes: "education for trauma-informed practice" and "applying theory into practice." Each had several subordinate themes. Organizations and their staff must recognize that operational change and ongoing training will be required. By adopting a trauma-informed approach, forensic mental health nurses can better understand their patients' traumatic experiences, improve their therapeutic relationships, and engage patients in collaborative care. Training in trauma-informed care should start with nurses who will change their personal practice and can support and train their colleagues.

Combatting occupational deprivation and advancing occupational justice in institutional settings: Using a practice-based enquiry approach for service transformation

Introduction Occupational deprivation is a risk for residents of institutions. This is problematic at several levels: it can cause diminution of individual capacities; such environments pose philosophical and practical challenges for occupational therapists and the erosion of human rights can be an issue. Occupational therapists in an Australian forensic mental health setting ‘reclaimed’ occupation-centred practice, committed to occupational justice and tackled the experience of occupational deprivation of patients through utilising a practice-based enquiry approach. Method A community of practice scholars used a practice-based enquiry approach – a type of action methods research – involving iterative cycles of data collection, analysis, critique and implementation of practice innovations. Findings Through the practice-based enquiry process, participants’ practice became more occupation-centred, based and focused, resulting in: the creation of more opportunities for patients, which combatted occupational deprivation and increased potential for community reintegration; enhanced professional satisfaction and identity; and increased institutional ‘valuing’ of the occupational therapy service. Conclusion Ameliorating occupational deprivation can be achieved through becoming occupation-centred and embracing a stated commitment to occupational justice in the challenging practice setting of a forensic hospital. The use of the deeply reflective process of practice-based enquiry was pivotal to this shift in focus for the group of occupational therapists who participated in this study and also contributed to enhanced practitioner satisfaction, identity, autonomy and confidence.

A systematic review of effective therapeutic interventions and management strategies for challenging behaviour in women in forensic mental health settings

ABSTRACTWomen in secure forensic mental health care require therapy and care that is responsive to their specific needs. Despite the policy recognition that women require a distinct service, evidence based practice is not available for this population. This review was undertaken in response to a clinical need within a medium secure unit in Glasgow that was experiencing high levels of challenging behaviour, in a female ward. The review aimed to identify effective strategies or interventions for the management of challenging behaviour in women in secure services and, therefore, improve practice and patient care. A synthesis of the findings from the 11 identified studies revealed variability in the approaches used to support women in forensic services, including: behavioural programmes; organisational change with a focus on staff training and support; medication; ECT and mechanical restraint. The challenging behaviours assessed included self-harm; physical and verbal aggression; suicide attempts and arson/fire setting. The majority of articles suggested some improvement in aspects of challenging behaviour, however this was limited by the lack of control groups and small sample sizes. Further investigation is required to find out whether interventions identified in this review can sustain a reduction in challenging behaviours in the long-term.

The next steps forward in determining “what works”.

In this issue, Papalia, Spivak, Daffern, and Ogloff (2019) report on their meta‐analysis that examined whether psychological treatments with adult violent offenders in correctional and forensic mental health settings are effective in preventing community recidivism and institutional misconduct. The meta‐analysis was methodologically rigorous, involving 27 independent studies, over 7,000 offenders, and adherence to the PRISMA guidelines. They found that although treatment significantly reduced violent and general/nonviolent community recidivism, the average effect for violent and general/nonviolent institutional misconduct was not statistically significant. Further, a series of moderator analyses revealed some statistical trends, but most of the effects were not statistically significant after an alpha‐level correction. Taken together, they concluded that psychological treatments, particularly if multi‐modal, have a small but positive effect on community recidivism. Recidivism and institutional misconduct have attracted attention from researchers for many years, yet meta‐analytic evidence regarding the effects of psychological treatment in reducing these outcomes has been lacking. Despite high numbers of justice‐involved individuals and near‐universal recognition of the importance of reducing recidivism and institutional misconduct, our understanding of “what works” is incomplete. Although the extant research base is limited by very few well‐controlled outcome studies and variable reporting of results, Papalia et al.’s (2019) meta‐analysis fills an important empirical gap. Based on their meta‐analysis, this commentary highlights several points that may be of interest to researchers and practitioners.

A meta‐analytic review of the efficacy of psychological treatments for violent offenders in correctional and forensic mental health settings.

A meta‐analytic review of the efficacy of psychological treatments for violent offenders in correctional and forensic mental health settings.

Role of health assistants in supporting forensic mental health

The present research investigates the pivotal function of healthcare assistants in providing assistance to individuals with mental health conditions in forensic environments. Health care assistants provide crucial assistance, facilitating patients in carrying out their everyday activities and enhancing their general well-being. Notwithstanding their substantial contributions, healthcare assistants often encounter difficulties associated with insufficient training and exposure to high-pressure circumstances, such as aggression and mental anguish. Therefore, it is crucial to comprehend their experiences, decision-making processes, and support requirements in order to improve their efficacy and well-being. Furthermore, it examines the consequences of these constraints on the safety of patients and the quality of treatment. The objective of this research is to identify areas for improvement in training and support systems by examining current literature and investigating the perspectives of HCAs. The results will help in the development of techniques that improve the proficiency and self-assurance of Health Care Assistants (HCAs), thereby helping both staff members and patients in forensic mental health settings.

Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices.

Reducing and eliminating the use of restrictive practices, such as seclusion and restraint, is a national priority for Australia's mental health services. Whilst legislation, organization and practice changes have all contributed to a reduction in these practices, forensic mental health services continue to report high rates. This paper details the findings of research that examined the experiences of nurses working in the inpatient forensic mental health setting. The research aimed to (i) document the experiences of nurses working in the forensic mental health setting, (ii) articulate their perceived unique skill set to manage challenging patient behaviours, and (iii) determine how their experiences and skill set can inform practice changes to reduce the use of restrictive practices. Thirty-two nurses were recruited from one Australian forensic mental health service. Data were collected using semi-structured interviews and analysed using inductive content analysis. Four categories were identified that influenced practice experiences: (i) working in a challenging but interesting environment, (ii) specialty expertize, (iii) exposure to aggression and resilience as a protective factor, and (iv) the importance of effective teamwork and leadership. Forensic mental health care is complex, highly specialized, and often delivered in an unpredictable environment. Whilst high rates of restrictive practices may be linked to the unique characteristics of forensic patients, training, teamwork, and leadership are critical factors influencing their use in this setting. Nurses working in this area need to be educated and supported to work confidently and safely with this high-risk patient cohort.

Evaluating the Introduction of the Safewards Model to a Medium- to Long-Term Forensic Mental Health Ward.

Care and treatment in forensic mental health wards can present with challenges when loss of hope and freedom, and aggression are present, which can then influence ward atmosphere and feelings of safety. Safewards is a model designed to address a range of conflict (e.g., aggression and self-harm) and containment (e.g., use of restrictive interventions) events and may provide a suitable approach to delivery of care in a forensic setting, while also addressing aggression, restrictive interventions, and ward atmosphere. The aim of this study was to evaluate the introduction of Safewards to a forensic mental health ward to determine suitability, and to explore if changes to conflict, containment, and ward atmosphere occurred. A mixed methods approach was used involving the collection of incident data related to conflict and containment, an assessment of the degree to which interventions were implemented, and an assessment of the social climate before and after implementation. Results suggested that there were fewer conflict events after Safewards was introduced; however, there did not appear to be any changes in the already low use of restrictive interventions. The Safewards interventions were implemented to a high degree of fidelity, and there was indication of an increase in a positive perception of ward atmosphere, supported by themes of positive change, enhanced safety, and respectful relationships. Safewards may assist in contributing to an improvement in the perception of ward atmosphere. To enhance implementation in a forensic mental health setting, there may be a need to consider additional elements to Safewards, pertinent to this setting.

The prison as a therapeutic music scene: Exploring musical identities in music therapy and everyday life in a prison setting

Whilst most research into music therapy with offenders focuses on music interventions in forensic mental health settings, less research exists into affordances of supporting musicking as an everyday practice in prisons. This article explores the prison as a music scene supported by a music therapist, showing how musicking forms an important part of the prison’s emotional geography. Through the presentation of findings from an ethnographic study of musical life in a low secure prison in Norway, the article shows how prisoners engage in music as a technology of self, affording the performance of caring and autonomous identities. We argue that supporting everyday musicking in the prison through music therapy fosters a therapeutic music scene, and that drawing on music as data in criminological research can contribute to more nuanced understandings of prisons.

Implementation of individual placement and support (IPS) into community forensic mental health settings: Lessons learned

Introduction Assessment of the effectiveness of individual placement and support in forensic mental health settings is a relatively new field of research despite evidence demonstrating its effectiveness in generic mental health settings. Method IPS was implemented into a community forensic mental health setting within a large National Health Service trust in the United Kingdom over 6 months. Using the Consolidated Framework for Implementation Research this paper describes the lessons learned from implementing individual placement and support into such settings. Results Our findings suggest that implementation of individual placement and support in forensic mental health settings is complex and requires robust planning and collaboration with internal and external agencies. Barriers to implementation included staff attitudes, difficulty engaging employers and lack of employment related performance indicators, and facilitators included the support of service managers and outside groups. Adaptations to the IPS model were made to address challenges encountered, including difficulty starting rapid job searches, concerns about stigma, lack of confidence, uncertainty around employment opportunities, offence restrictions and lack of interest from potential employers. Conclusion This paper adds to the limited literature in the field. Findings are relevant to practitioners and service providers who wish to implement individual placement and support services for people with mental disorder and offending histories.

Staff perceptions of positive behavioural support in a secure forensic adult mental health setting

PurposeChallenging behaviour has been a concern across forensic services. Traditionally these have been managed reactively using medication, seclusion and restraint; however, there is growing evidence that these approaches are ineffective and counter-therapeutic. A number of reports have recommended the use of preventative approaches such as positive behavioural support (PBS). The purpose of this paper is to identify “how staff within a secure forensic mental health setting perceived the application of PBS?”Design/methodology/approachIn total, 11 multi-disciplinary staff were interviewed and thematic analysis was used to identify themes.FindingsFive themes were identified: “The Functions”, “Appraising a new Approach”, “Collaborative Challenges”, “Staff Variables” and “Organisational Issues”.Practical implicationsPBS enables staff to understand challenging or risky behaviour. It empowers patients via collaboration, although there can be some challenges to this. Services need to invest in training, support and leadership to ensure the model is embed and promote fidelity. Consideration needs to be given to how quality of life can be improved within the limits of a forensic setting.Originality/valueNo previous studies asking staff about their experiences of PBS within a forensic mental health context.

Constructing ‘the Psychopath’

Background: Psychopathy is a controversial psychological construct used within forensic settings to understand the psychology of forensic service users. Contemporary research into psychopathy indicates ontological confusion, limitations with assessment practices and the presence of a negative bias towards individuals identified as psychopathic. Aims: A moderate social constructionist epistemology underpins this study. Its purpose was to widen the clinical frame of psychopathy via sociological inquiry through an examination of how ‘the psychopath’ is constructed discursively by a particular group of specialists working directly with individuals with a psychopathy label. Methods: Subjects were eight clinical psychologists currently working throughout the UK in forensic mental health settings (low, medium and high-secure hospitals). Semi-structured interviews were conducted and the data were analysed qualitatively, using Discourse Analysis methods. Findings: Analysis demonstrated that persons with psychopathy are constructed as problematised individuals, located within four overarching, recurrent discursive sites: dangerous, challenging, manipulative, and psychologically deficient. Participants utilised ‘at risk’ and ‘trauma’ discourses to explain the aetiology of psychopathy and ‘intuition’ talk was employed as a marker of the presence of psychopathy. The findings of the study and their clinical implications are discussed.

Assessing Protective Factors for Violence Risk in U.K. General Mental Health Services Using the Structured Assessment of Protective Factors.

Violence risk assessment and management are key tasks in mental health services and should be guided by validated instruments covering both risk and protective factors. This article is part of an international effort to validate the Structured Assessment of Protective Factors (SAPROF) for violence. The SAPROF, Historical, Clinical, Risk Management-20 (HCR-20) and the Psychopathy Checklist-Screening Version (PCL-SV) were administered in a sample of 261 patients in U.K. forensic, general inpatient, and community mental health settings. There was significant variation between these groups on SAPROF scores with fewer protective factors in the forensic group. The prospective validity of the SAPROF for nonviolence in the general inpatient and community samples was moderate (area under the curve [AUC] = .60). Adoption of the SAPROF or similar instruments as a supplement to risk-focused assessments has the potential to improve awareness of protective factors and enhance therapeutic engagement in a range of mental health services.

Social climate in forensic mental health settings: A systematic review of qualitative studies

Abstract Social climate is a commonly evaluated aspect of inpatient forensic mental health settings. However, there is little clarity in the literature on the components of social climate. To identify these components, qualitative studies of staff and patient experiences of social climate were systematically reviewed using best fit framework synthesis. An a priori framework was developed based on nine existing models of social climate. A systematic search identified twenty studies of sufficient quality to be included in the review. These studies included staff and patient perspectives across all levels of inpatient forensic settings. In all twenty-two themes were identified in the review papers. From these themes, a model of social climate was developed. Seven factors were identified as part of the social climate, including the therapeutic relationship, care and treatment orientation, the secure base and four aspects of the ward environment. The findings indicate that common measures of social climate may not fully represent the construct. Themes related to the patient group, the staff group, the physical environment and system level factors were identified as influencing social climate. The model described allows for consideration of interventions to positively influence social climate.