Forensic Psychiatric Settings Research Articles

Psychosocial approaches for individuals with schizophrenia in correctional and forensic psychiatric settings: a rapid review

PurposeThe purpose of this paper is to identify the psychosocial approaches that have been studied and for which positive outcomes have been reported for individuals with schizophrenia in correctional and forensic psychiatric settings.Design/methodology/approachA rapid review of the literature was undertaken. A search was conducted on MEDLINE and PsycNET electronic databases. Each identified approach was analyzed to define their types and components.FindingsIn total, 24 studies pertaining to 18 different psychosocial approaches were identified. Half of the studies used a quasi-experimental design with control group. Most frequent outcomes reported were improvements in knowledge about illness and problem solving. Seven studies reported positive outcomes related to issues more specific to this population (violence, aggression, and recidivism). Approaches associated with these studies used mainly traditional cognitive behavior therapy and cognitive remediation. The focus was on neurocognition, social cognition, social skills, emotion management and problem solving.Practical implicationsThis rapid review may enlighten clinical settings on psychosocial approaches for which positive outcomes have been reported with individuals with schizophrenia in correctional and forensic psychiatric settings. The picture obtained supports the idea of using integrated rehabilitation approaches that cover the aforementioned intervention focuses with this population.Originality/valueA significant contribution of the rapid review is based on the analysis of the psychosocial approaches identified. This process offers a closer look at the nature and content of the approaches used according to the outcomes reported.

Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis

Background and AimsViolent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings. MethodsThe nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of these tools in forensic psychiatric inpatient settings. Risk assessment instruments were separated into those designed for imminent (within 24 hours) violence prediction and those designed for longer-term prediction. A range of accuracy measures and descriptive variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2. Summary performance measures (sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, and area under the curve value) and HSROC curves were produced. In addition, meta-regression analyses investigated study and sample effects on tool performance. ResultsFifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71–0.85) compared with longer-term tools (AUC 0.68; IQR: 0.62-0.75). Other performance measures indicated variable accuracy for imminent and longer-term tools. Meta-regression indicated that no study or sample-related characteristics were associated with between-study differences in AUCs. InterpretationThe performance of current tools in predicting risk of violence beyond the first few days is variable, and the selection of which tool to use in clinical practice should consider accuracy estimates. For more imminent violence, however, there is evidence in support of brief scalable assessment tools.

English vs Dutch high secure hospitals: service user perspectives

PurposeThe purpose of this paper is to describe service users’ perspectives on the difference between high secure long-stay forensic psychiatric services in the Netherlands and high secure forensic psychiatric care in England. These perspectives are relevant in considering the benefits of a similar long-stay service in England.Design/methodology/approachA current in-patient detained in a high secure hospital in England and other mental health service users and carers with experience in forensic-psychiatric settings were asked to watch a documentary on a Dutch high secure long-stay service. Then they were invited to make comparisons between this service and high secure care in England. These perspectives were gained in the context of their membership of the Service User Reference Group of an externally funded study on long-stay in forensic-psychiatric settings in England.FindingsThe small group of participants highlighted the importance of relational security, meaningful occupation, autonomy, positive therapeutic relationships with staff and a homely environment for those with lengthy admissions and perceived these to be better met in the Dutch service. These factors might contribute to improved quality of life that services should strive to achieve, especially for those with prolonged admissions.Practical implicationsPerspectives of service users with lived experience of long-stay in forensic settings are important in informing service developments. Lessons can be learnt from initiatives to improve the quality of life in long-stay services in other countries and consideration be given on how to best manage this unique group.Originality/valueTo the authors’ knowledge this is the first study asking service users about their view on forensic services in other countries. The findings suggest that service users have valuable contributions to make to aid service developments and should be involved in similar such exercises in the future.

Interrater Reliability of Psychopathy Checklist–Revised: Results on Multiple Analysis Levels for a Sample of Patients Undergoing Forensic Psychiatric Evaluation

Scores from the Psychopathy Checklist–Revised (PCL-R) are used to support decisions regarding personal liberty. In our study, performed in an applied forensic psychiatric setting, intraclass correlation coefficients (ICC) for absolute agreement, single rater (ICCA1) were .89 for the total score, .82 for Factor 1, .88 for Factor 2, and .78 to .86 for the four facets. These results stand in contrast to lower reliabilities found in a majority of field studies. Disagreement among raters made a low contribution (0%-5%) to variability of scores on the total score, factor, and facet level. For individual items, ICCA1 varied from .38 to .94, with >.80 for seven of the 20 items. Items 17 (“Many short-term marital relationships”) and 19 (“Revocation of conditional release”) showed very low reliabilities (.38 and .43, respectively). The importance of knowledge about factors that can affect scoring of forensic instruments (e.g., education, training, experience, motivation, raters’ personality, and quality of file data) is emphasized.

Nursing Diagnoses Panorama in a Swedish Forensic Psychiatric Setting Using NANDA-International Taxonomy.

Data were collected from electronic patient records of 55 patients in a medium-secure forensic psychiatric setting in Sweden. Anonymized data were entered into a database where entries were transformed into figures. Descriptive statistics were used, and frequencies, means, and percentages were calculated. The variables employed were characteristics and related factors, according to NANDA-International (NANDA-I) and International Statistical Classification of Dieseases and Related Heatlh Problems, 10th Revision (ICD-10), diagnoses. The patients had between 1 and 13 NANDA-I diagnoses each. Forty-one of the 55 patients had psychosis as the primary ICD-10 code. The identified nursing diagnoses described the patients' status upon arrival in the forensic psychiatric setting. Of the 55 patients, entries in the patient records describing 300 signs and symptoms (i.e., characteristics and related factors) were found. From these signs and symptoms, 371 entries that fit NANDA-I diagnoses were identified, representing 20 different NANDA-I diagnoses. NANDA-I diagnoses individualize patient care, making care person centered. NANDA-I is used all over the world and has the potential to make nursing care structured, measurable, and internationally comparable.

Clinician Perspectives of Inpatient Forensic Psychiatric Rehabilitation in a Low Secure Setting: A Qualitative Study

There is a dearth of research into what low secure forensic psychiatric rehabilitation means in Australia and internationally. The aim of this study was to understand clinician perspectives of forensic psychiatric rehabilitation in a low secure setting in Australia and offer insight into a model of care. A qualitative methodology was chosen with separate semi-structured interviews being conducted with staff members involved in decision-making for forensic psychiatric patients in a rehabilitation unit. Analysis of the interviews identified three domains that the questions related to: ‘defining and describing security’, ‘defining and describing low secure forensic psychiatric rehabilitation’ and ‘describing the role of staff and services in a low secure forensic psychiatric rehabilitation setting’. Where relevant, themes were abstracted from the questions that related to these domains. This study revealed that clinicians had a varied understanding of definitions for security but a similar understanding of what low secure forensic psychiatric rehabilitation means, what patients are suitable and the general goals of rehabilitation in this setting. Further research is needed on low secure rehabilitation and specific models of care. There is also a need to develop clear definitions for both security and rehabilitation in low secure forensic psychiatric settings.

Comparison of Structure and tasks of Forensic Psychiatry in Iran and European Countries

Background: The purpose of the study was to compare forensic psychiatric setting in Iran with European countries. Methods: First a qualitative study (experience expression) was done, interviewing the forensic psychiatrics. Then to understand the sections of forensic psychiatry department, articles, scientific references and the relevant sites were reviewed. Their work was analyzed using emails and phone calls. Recording data forms that included different services, the way they worked and human resources’ potential in forensic psychiatric system in any of the chosen countries were filled accordingly. Findings: In most studied European countries, the examination method, treatment, rehabilitation and post discharge care are the same. Observing the patient’s behavior and social interactions is one of the most important diagnostic tools. In Europe, forensic psychiatric activities’ focus is on criminal matters: risk assessment, treatment and rehabilitation of criminal patients. The more executive diagnostic facilities of forensic psychiatry and secure mental hospitals with special deparments are important factors that make significant difference. Conclusion: Despite the differences that exist in European departments of forensic psychiatry’s activities, similarities are observed in factors such as mental patients’ examination method, diagnostic and treatment facilities, preparing a psychiatric report for the court. The activity of Iranian’s system isn’t functional enough in comparison to European system, due to factors like lack of standardized and secure diagnostic facilities, and limited access to criminal patients and courts. To improve the system, our country should consider some actions such as: establishment of standardized sections in prisons and psychological hospitals, longterm program to establish special hospitals, using common and standard tools of risk assessment and establishment of follow up clinics and nursing (guardian) houses for post discharge care of criminal patients.

Individuals’ experiences of sexual offending therapy in a forensic psychiatric setting

ABSTRACTThere is a paucity of research exploring individuals’ experiences of sexual offending therapy, particularly in forensic psychiatric settings. This study qualitatively explored the perspectives of six male medium-secure patients regarding the treatment programme they completed to address their sexual offending behaviour. Thematic analysis of interviews generated two themes: the experience of transition through the programme and the experience of engagement. The importance of gaining service-user feedback and the implications for programme design and delivery are discussed.

The Role of Dimensional Personality Psychopathology in a Forensic Inpatient Psychiatric Setting.

The Minnesota Multiphasic Personality Inventory-2 Restructured Form is a widely used measure of psychopathology and includes the Personality Psychopathology Five (PSY-5) scales, which measure dimensional maladaptive personality traits similar to those in the DSM-5 alternative model for personality disorder (PD) diagnosis. The current study evaluated the role of these dimensional personality psychopathology characteristics in a sample of 1,110 inpatients in a forensic psychiatric setting, where personality psychopathology plays a significant but understudied role. The authors examined the extent to which dimensional personality psychopathology characteristics (as measured by the PSY-5) were associated with borderline and antisocial PD diagnoses and institutional aggression. Results support the usefulness of measuring dimensional personality traits for understanding PD diagnoses, as well as incidents of institutional aggression. More specifically, the PSY-5 scales appear to measure the core features of borderline and antisocial PDs. This study supports the inclusion of dimensional personality assessment in understanding aggressive behavior in inpatient settings.

Evaluation of the Response Bias Scale and Improbable Failure Scale in assessing feigned cognitive impairment.

The present study evaluated the Response Bias scale (RBS), a symptom validity test embedded within the Minnesota Multiphasic Personality Inventory (MMPI)-2 Restructured Form (MMPI-2-RF) that assesses for feigned neurocognitive complaints, in a sample of pretrial incompetent to stand trial (IST) criminal defendants. Additionally, we examined the Improbable Failure (IF) scale, a performance validity test embedded within the Structured Interview of Reported Symptoms, Second Edition (SIRS-2), which similarly assesses for feigned cognitive impairment (FCI). Results indicated that both the RBS (area under the curve [AUC] = .76) and IF scale (AUC = .72) achieved moderate classification accuracy using the Test of Memory Malingering (TOMM) as the criterion. Further, the RBS and IF scale appeared to be most useful for screening out those defendants who presented as genuine (specificity = 99% and 88%, respectively), and less effective at classifying those defendants suspected of feigning according to the TOMM (sensitivity = 29% and 46%, respectively). In order to identify a significant proportion of IST defendants who may be feigning impairment, considerably lower cutoff scores than those recommended in each measure's manual were evaluated. An RBS T score of 63 (sensitivity = 86%; specificity = 37%), and IF scale raw score of 2 (sensitivity = 80%; specificity = 43%), was required to achieve ≥80% sensitivity; these alternate cutoff scores may therefore be useful when screening inpatient forensic psychiatric IST defendants. Further, the 2 scales effectively predicted TOMM classification in combination, although only the RBS significantly contributed to the model. Implications for the assessment of FCI in forensic psychiatric settings are discussed. (PsycINFO Database Record

Risk Factors Associated With Inpatient Violence During Medium Security Treatment.

Violence is a common phenomenon both in regular and forensic psychiatric settings, and has a profound impact on staff and other patients. Insight into the individual risk factors associated with violence in forensic psychiatric settings is rare and is therefore the subject of this research. A retrospective file study in three medium security units in Flanders was conducted to compare non-violent inpatients with inpatients who engaged in (verbal and physical) violent behavior. Binary logistic regression analyses were used to examine which variables contributed independently to the risk of violence. The results showed that absconding during treatment was independently associated with physical violence. A personality disorder diagnosis and general non-compliance with treatment were associated with verbal violence. Both types of violence predicted early termination of treatment. Contrary to previous research, the results from the risk assessment tools were not associated with inpatient violence. Clinical implications are discussed and include, among others, that clinicians should remain vigilant for early warning signs of non-compliance during treatment.

Validating the Hamilton Anatomy of Risk Management-Forensic Version and the Aggressive Incidents Scale.

The Hamilton Anatomy of Risk Management-Forensic Version (HARM-FV) is a structured professional judgement tool of violence risk developed for use in forensic inpatient psychiatric settings. The HARM-FV is used with the Aggressive Incidents Scale (AIS), which provides a standardized method of recording aggressive incidents. We report the findings of the concurrent validity of the HARM-FV and the AIS with widely used measures of violence risk and aggressive acts, the Historical, Clinical, Risk Management-20, Version 3 (HCR-20V3) and a modified version of the Overt Aggression Scale. We also present findings on the predictive validity of the HARM-FV in the short term (1-month follow-up periods) for varying severities of aggressive acts. The results indicated strong support for the concurrent validity of the HARM-FV and AIS and promising support for the predictive accuracy of the tool for inpatient aggression. This article provides support for the continued clinical use of the HARM-FV within an inpatient forensic setting and highlights areas for further research.

From Clozapine to Cognitive Remediation.

Although a minority of persons with schizophrenia (SCZ) commits violent acts, SCZ remains a risk factor for violence. Here, we present a broad overview of evidence-based treatments for violence in SCZ, including biological and psychosocial interventions. We conducted MEDLINE and PsychINFO literature searches to retrieve articles relating to treatments for violent, hostile, or aggressive behaviours in SCZ. Clozapine shows the strongest evidence for treating the acute violence of SCZ. Other atypical antipsychotics also possess antiaggressive effects, although the evidence is not as robust as that for clozapine. Psychosocial treatments can be useful adjuncts to pharmacotherapy once patients' positive symptoms have stabilized. Cognitive behavioural therapy for psychosis and cognitive remediation are 2 psychosocial interventions that have demonstrated positive outcomes for violence in SCZ. Most psychosocial studies that examined violence as an outcome were conducted in forensic psychiatric settings. Effective treatments exist for persons with SCZ who pose a risk for violent and aggressive behaviour, although the overall evidence base remains relatively weak. More randomized controlled trials of programs showing evidence for reduction of violence in SCZ are required. Further research should delineate which patients could benefit from multimodal treatment and where and when such treatments are optimally delivered.

Assessing the reliability, predictive and construct validity of historical, clinical and risk management-20 (HCR-20) in Mexican psychiatric inpatients

abstractIntroduction: Assessing dangerousness to gauge the likelihood of future violent behaviour has become an integral part of clinical mental health practice in forensic and non-forensic psychiatric settings, one of the most effective instruments for this being the Historical, Clinical and Risk Management-20 (HCR-20). Objective: To examine the HCR-20 factor structure in Mexican psychiatric inpatients and to obtain its predictive validity and reliability for use in this population. Method: In total, 225 patients diagnosed with psychotic, affective or personality disorders were included. The HCR-20 was applied at hospital admission and violent behaviours were assessed during psychiatric hospitalization using the Overt Aggression Scale (OAS). Construct validity, predictive validity and internal consistency were determined. Results: Violent behaviour remains more severe in patients classified in the high-risk group during hospitalization. Fifteen items displayed adequate communalities in the original designated domains of the HCR-20 and internal consistency of the instruments was high. Conclusion: The HCR-20 is a suitable instrument for predicting violence risk in Mexican psychiatric inpatients.

Getting to know the person behind the illness - the significance of interacting with patients hospitalised in forensic psychiatric settings.

To describe what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings. Relationships between staff and patients in forensic psychiatric settings should be grounded in trust and confidence, and the patients need opportunities for emotional reconciliation. However, relationships can be challenging for nurses, who sometimes distance themselves from patients' expressions of suffering. The role of forensic mental health nurses is nebulous, as are the prescriptives and the implementation of nursing practices. Qualitative descriptive design. In-depth interviews with five nurses who all work in forensic psychiatric settings. We present a descriptive analysis of what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings. The results are presented in two main categories: (1) getting to know the person behind the illness and (2) making a difference. Care in forensic psychiatry needs to shift towards a more long-term view of the role of nursing, focusing less on the traditional and stereotypical identity of the productive nurse and more on the care given when nurses slow down and take the time to see the patients as individuals. Establishing trusting relationships with patients in forensic psychiatric settings is viewed as a less oppressive way to control patients and guide them in directions that are preferable for the nurses and for the society. Nurses may use simple strategies in their daily practice such as sitting on the sofa with patients to establish trust. We stress that nurses should abandon policing roles and custodial activities in favour of guiding principles that promote individual recovery, treatment and health-promoting care.

The relationship between trust in work colleagues, impact of boundary violations and burnout among staff within a forensic psychiatric service

Purpose – The purpose of this paper is to examine the relationship between trust and burnout among mental health professionals working within a forensic psychiatric setting. The association between these factors and boundary violations was also examined. Design/methodology/approach – Mental health professionals (n=117) completed the Maslach Burnout Inventory and a measure of their trust in co-workers. A series of 12 vignettes was also designed to assess the frequency and impact of boundary violations by clients. Findings – Propensity to trust was found to be predictive of personal accomplishment. A higher propensity to trust others was associated with lower levels of emotional exhaustion and depersonalisation. It was also associated with greater cooperative behaviour. Higher frequency of boundary violations reported by professionals was associated with lower levels of perceived trust and cooperative behaviours among colleagues, and increased depersonalisation. In addition, professionals reporting more of a perceived impact of boundary violations, reported higher emotional exhaustion and depersonalisation. The results also indicate that younger professionals reported higher levels of emotional exhaustion and depersonalisation, whereas older professionals were more positive regarding their competence and sense of accomplishment. Research limitations/implications – The results are discussed in terms of the development of trust within teams as an effective strategy to reduce the development of burnout. Implications are made for the importance of reflective practice and clinical supervision in developing positive working relationships with clients, and providing a safe environment to discuss professional conflict. The importance of supporting younger professionals has also been highlighted. Originality/value – This is the first research paper to explore the relationship between trust within teams and the development of burnout within forensic psychiatric services.

The impact of forensic work on home life: the role of emotional labour, segmentation/integration and social support

Purpose – Adopting a person-environment (P-E) fit approach, the purpose of this paper is to examine the role of emotional labour, segmentation/integration and social support in the development of work-home conflict. Design/methodology/approach – Mental health professionals (n=118) completed the work-home conflict and home-work conflict scales (Netemeyer et al., 1996), the segmentation preferences and supplies scales (Kreiner, 2006) and the Mann Emotion Requirements Inventory (Mann, 1999). A social support checklist was also developed to assess the perceived value of work and non-work sources of support. Findings – Contrary to expectation, emotional labour was associated with lower levels of work-home conflict. There was no evidence found for the relevance of a P-E fit approach, rather the results indicated that the perception that the organisation supports the separation of work and home is sufficient in ameliorating work-home conflict. In addition, work-based support was found to reduce work-home conflict. Research limitations/implications – The importance of support within the work environment as a way of reducing work-home conflict has been highlighted. That is, providing a safe environment to discuss anxieties and concerns is a fundamental factor when developing organisational support structure. The importance of providing professionals with choice regarding their preference to segment or integrate work and home has also been highlighted. Based on the contradictory findings with regards to emotional labour and work-home conflict, future research should aim to further examine this relationship within a forensic psychiatric setting. Originality/value – This is the first research paper to explore the role of emotional labour, segmentation/integration and social support in the development of work-home conflict.

Policies on sexual expression in forensic psychiatric settings in different European countries.

BackgroundSexual expression by forensic psychiatric patients is poorly researched.MethodsForensic experts representing 14 European countries were interviewed to explore the diverse ways in which sexual expression within forensic settings is handled.ResultsNo country had a national policy, although many had local policies or shared practices. Progressive approaches to patient sexuality were evident in nine of the countries sampled. The UK appeared the most prohibiting and excluding, its protocols apparently based on risk aversion and lack of emphasis or consideration of patients’ sexual needs.ConclusionsUniform national policy supporting patients’ sexual expression would provide significant improvements.Electronic supplementary materialThe online version of this article (doi:10.1186/s13033-016-0037-y) contains supplementary material, which is available to authorised users.

Ethical issues of long-term forensic psychiatric care

Summary Forensic psychiatry is a subspecialty of clinical psychiatry that operates at the interface between law and psychiatry. It is concerned with patients who have a mental disorder as well as having committed an offence, often serious. Forensic psychiatric institutions are high-cost/low-volume services that impose significant restrictions upon their residents. Patients may be detained in those services against their will for lengthy periods, potentially life-long. The purpose of this detention is seen as two-fold: care and treatment for the patient and protection of the public from harm from the offender. Here we review the ethical issues around such long-term detention. We base our observations on a review of relevant literature and from focus groups with professionals working in forensic psychiatric settings. Additionally, we visited three institutions in the UK where long-stay forensic psychiatric patients receive care. A number of factors have been identified contributing to long-term stay (long-stay) in forensic psychiatric care, including organisational factors (e.g., lack of beds in less secure settings) and patient characteristics (severity of psychopathology and offending). Long-stay in a forensic psychiatric setting – which is often longer than had the patient received a prison sentence for the same offence – poses significant ethical and human rights issues, particularly when it is unclear whether the treatments offered benefit the patient and when risk management considerations may outweigh the best interests of the patient. The main topics of concern identified by our participants included “system failures”, “avoidance of warehousing”, “importance of hope”, “denial” and long-stay units and “quality of life”. Participants were concerned that the system is set up in a way that does not allow patients with complex and long-term needs to move to more appropriate, less restrictive settings and that the issue of “long-stay” is met with denial. In order to avoid warehousing and maintain hope, those we spoke to felt it was important to not give up on patients and continue to deliver treatment, almost regardless of its effect. Providing long-stay patients with a good quality of life was seen as important, though we found that the stated ambitions were not always matched by the reality of the units we visited. Despite the stated need to provide something “different” for long-stay patients, the units were nevertheless very restrictive in their approach (e.g., prohibition of sexual expression). Professionals seemed to lack a more ambitious and creative vision to create something truly distinct. We discuss possible solutions, including explicitly maximising the quality of life of those detained, limiting the time of detention to equal the sentence length of non-disordered offenders and locating the public protection function of the management of mentally disordered offenders within the criminal justice rather than the health care system. The implementation of such radical solutions, however, might be hampered by the difficulties in changing entrenched values and procedures, to the point that diverse stakeholders join together in maintaining the status quo.

Never ever? Characteristics, outcomes and motivations of patients who abscond or escape: A 5-year review of escapes and absconds from two medium and low secure forensic units.

Absconds and escapes by psychiatric patients from secure forensic psychiatric settings create public anxiety and are poorly understood. To describe secure hospital patients who escape from within the secure perimeter or abscond, and test for differences between these groups. Escapes and absconds between 2008 and 2012 from the medium and low secure forensic psychiatric inpatient units of two London National Health Service Trusts were identified through the Trusts' databases. Demographic, offending, mental health and incident data were extracted from records for each. Seventy-seven incidents, involving 54 patients, were identified over the five years. These were 13 escapes involving 12 patients, representing a rate of 0.04 per 1000 bed days, and 64 absconds involving 42 patients, a rate of 0.26 per 1000 bed days; 15 (28%) patients were absent without leave more than once. Over half of the patients came back voluntarily within 24 hours of leaving. Over 50% of them had drunk alcohol or taken drugs while away from the unit. Escapees were more likely to be transferred prisoners and to have planned their escape, less likely to return to the unit voluntarily and away longer than patients who absconded. Offending was rare during unauthorised leave--just three offences among the 77 incidents; self-harm was more likely. Motives for absconding included: wanting freedom or drink or drugs, family worries and/or dissatisfaction with aspects of treatment. Escapes or absconding from secure healthcare units have different characteristics, but may best be prevented by convergent strategies. Relational security is likely to be as important for foiling plans for the former as it is for reducing boredom, building strong family support and managing substance misuse in the latter.