High Secure Forensic Hospital Research Articles

Forensic Mental Health Nurses' Perceptions and Experiences of Trauma-Informed Care in a High-Secure Hospital.

Implementation of trauma-informed care (TIC) into forensic clinical practice may contribute to positive outcomes for both patients and staff. The current study aimed to describe forensic mental health nurses' perceptions and experiences of using TIC within a high-secure forensic hospital. Twenty-seven forensic mental health nurses were interviewed regarding their experiences of using TIC within a high-secure hospital. Participants recognized the importance of understanding the past traumatic experiences of patients in their care but described a number of barriers to the implementation of TIC. A lack of organizational support, the negative impact of patient psychopathology on nurse well-being, and environmental factors were all perceived to negatively impact the successful delivery of TIC. Participants also discussed a widespread lack of knowledge and confidence in the application of TIC but expressed great desire for training to improve service delivery. The application of TIC into daily clinical practice appears to be suboptimal. To support nurse and patient well-being and contribute to a highly skilled trauma-informed workforce, further training in this area is vital. Training in TIC may contribute to enhanced patient outcomes and promote nurse well-being and should be supported organizationally with sufficient resources.

``Getting People Back Into the Community'': Forensic Mental Health Nurses' Perceptions and Experiences of the Recovery Model Within a High-Secure Hospital.

The implementation of the recovery model into forensic mental health care promotes hope and has important implications for inpatients' community reintegration. This study aimed to describe forensic mental health nurses' perceptions and experiences of providing care using the recovery model within a high-secure forensic hospital in Queensland, Australia. Twenty-seven forensic mental health nurses were interviewed regarding their perceptions and experiences of providing recovery-oriented care within a high-secure forensic hospital. The participants described an individualized approach to recovery, both in the goals developed and in the level of support they required. There was an overarching shared goal across the participant group, which was focused on supporting patients to reintegrate back into the community. Inadequate resources (both internal and external), the severity of patient psychopathology, legal constraints, and the nursing role within the broader treating team were all perceived to present challenges to utilizing the recovery model within a high-secure forensic hospital. To fully realize the potential of the recovery model, a system-wide reconceptualization is necessary.

What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital

PurposeIncidents of violence and aggression are a regular occurrence within adult forensic mental health inpatient settings and often lead to the use of restrictive practices such as seclusion. Such events are frequently attributed to the complexity of the patients. Research commonly focuses on patient’s characteristics and their association with seclusion use. Less attention has been centred on forensic mental health nurses’ attitudes to seclusion and the association of nursing staff characteristics.Design/methodology/approachA cross-sectional survey was undertaken using a standardised questionnaire, “Survey of Nurses’ Attitudes to Seclusion”. Responses were received from n = 147 nurses at a high secure forensic mental health hospital in the UK.FindingsKey findings indicate that most participants believed seclusion should remain part of clinical practice. A correlation was identified between forensic mental health nurses’ attitudes to seclusion use and their characteristics: gender, age range, educational level and experience.Practical implicationsThis paper presents novel information on seclusion reduction opportunities through modifiable workforce factors such as gender-sensitive rostering and staff training and development. Furthermore, recruitment and retention strategies should be prioritised so forensic mental health is perceived as an attractive career and a safe workplace.Originality/valueThe paucity of research in this area has prompted calls for further research to explore nursing staff characteristics and seclusion use. This is particularly important now due to the current global difficulty in the recruitment and retention of mental health nurses.

A service evaluation of passive remote monitoring technology for patients in a high-secure forensic psychiatric hospital: a qualitative study

BackgroundTechnology has the potential to remotely monitor patient safety in real-time that helps staff and without disturbing the patient. However, staff and patients’ perspectives on using passive remote monitoring within an inpatient setting is lacking. The study aim was to explore stakeholders’ perspectives about using Oxehealth passive monitoring technology within a high-secure forensic psychiatric hospital in the UK as part of a wider mixed-methods service evaluation.MethodsSemi-structured interviews were conducted with staff and patients with experience of using Oxehealth technology face-to-face within a private room in Broadmoor Hospital. We applied thematic analysis to the data of each participant group separately. Themes and sub-themes were integrated, finalised, and presented in a thematic map. Design, management, and analysis was meaningfully informed by both staff and patients.ResultsTwenty-four participants were interviewed (n = 12 staff, n = 12 patients). There were seven main themes: detecting deterioration and improving health and safety, “big brother syndrome”, privacy and dignity, knowledge and understanding, acceptance, barriers to use and practice issues and future changes needed. Oxehealth technology was considered acceptable to both staff and patients if the technology was used to detect deterioration and improve patient’s safety providing patient’s privacy was not invaded. However, overall acceptance was lower when knowledge and understanding of the technology and its camera was limited. Most patients could not understand why both physical checks through bedroom windows, and Oxehealth was needed to monitor patients, whilst staff felt Oxehealth should not replace physical checks of patients as reassures staff on patient safety.ConclusionsOxehealth technology is considered viable and acceptable by most staff and patients but there is still some concern about its possible intrusive nature. However, more support and education for new patients and staff to better understand how Oxehealth works in the short- and long-term could be introduced to further improve acceptability. A feasibility study or pilot trial to compare the impact of Oxehealth with and without physical checks may be needed.

Alexithymia and Forgiveness Levels of Forensic Psychiatric Patients.

The current cross-sectional study was performed to examine levels of alexithymia and forgiveness in forensic psychiatric patients. Data were collected between March 2022 and August 2022 at a high-security forensic psychiatric hospital affiliated with a city hospital in Turkey. A personal information form prepared by the researchers, the Toronto Alexithymia Scale, and the Heartland Forgiveness Scale were used to obtain data. Participants comprised 132 forensic psychiatric patients who agreed to participate in the study. A significant negative correlation was found between alexithymia and forgiveness levels of participants (p < 0.01, r = -0.259). In other words, as alexithymia levels increased, participants were found to be less forgiving. In addition, results suggest that forensic psychiatric patients are susceptible to alexithymia and higher levels of forgiveness. Determining forgiveness and alexithymia levels of forensic psychiatric patients will contribute to the structuring of care to be offered to these patients. [Journal of Psychosocial Nursing and Mental Health Services, 62(6), 27-35.].

A preliminary study exploring the nature of aggression supportive beliefs in a forensic psychiatric sample

PurposeThis preliminary study aims to investigate and describe aggression-supportive normative beliefs among patients of a high-secure hospital.Design/methodology/approachTherapy data from a sample of high-secure forensic hospital patients (N = 11) who had participated in Life Minus Violence-Enhanced, a long-term violence therapy, was examined using interpretative phenomenological analysis (IPA). During therapy, cognitions linked to past incidences of aggression were explored using aggression choice chains.FindingsIPA was applied to data generated through this process to examine the presence and nature of normative beliefs reported, identifying seven themes: rules for aggressive behaviour; use of violence to obtain revenge; processing emotions with violence; surviving in a threatening world; do not become a victim; using violence to maintain status; and prosocial beliefs.Originality/valueFindings demonstrate that forensic patients have specific aggression-supportive normative beliefs, which may be malleable. Limitations and implications are discussed.

Adverse Childhood Experiences and Offending as a Function of Acquired Brain Injury Among Men in a High Secure Forensic Psychiatric Hospital.

Acquired brain injury (ABI) is a serious problem that disproportionately affects individuals in correctional services, but relatively little is known about ABI risks and correlates in forensic psychiatric services. We conducted a retrospective chart review of all admissions to a high secure forensic hospital in Ontario, Canada from January 2009 to December 2012 (n = 637) and collected data on ABI, psychiatric diagnoses, developmental disadvantage, criminal offending, and in-hospital aggression. A k-means cluster analysis was employed to assess risk factors by which men with ABI could be identified and multivariate general linear models were used to identify ABI-related differences in offending history and in-hospital aggression. One-fifth of the men had a documented ABI indicator. Based on our cluster analysis, ABI was more likely to be identified by greater adverse childhood experiences (ACEs), more health problems from pregnancy to childhood, and lower socioeconomic status, suggesting that ABI within the forensic context is associated with greater developmental disadvantage. Men with ABI had more serious pre-admission offences, but not more serious admission offences or in-hospital aggression. Men with ABI were more likely than those without to have higher scores on the Violence Risk Appraisal Guide or to be diagnosed with mood and personality disorders, and less likely to have a schizophrenia diagnosis, suggesting an association between ABI and general mental health pathologies but not with psychotic illness. The disadvantage of ABI among men in forensic psychiatric hospitals is most likely evinced in antisocial behaviour rather than serious mental illness. Given that ACEs are likely to precede or co-occur with ABI, strategies that mitigate ACEs hold promise for ABI prevention.

Entering the world of lock and key: the impact of an educational visit to a high secure forensic hospital on psychology students’ attitudes towards the patients within

ABSTRACT Secure forensic hospitals aim to reverse adversity and promote personal safety and mental health well-being for those admitted. These hospitals are also well-placed to make the case for the importance of inclusion and reintegration after a period of enforced community exclusion (through detention under the Mental Health Act). Given the operational and procedural security required for the therapeutic regimes in these settings, only essential visitors are typically given access. This makes it challenging to promote awareness and understanding about patients with forensic and mental health histories. In this study, the impact of a one-day visit to a high-security forensic hospital by psychology students (n = 123), which included face-to-face contact with patients, was studied for its potential to reduce negative attitudes about this population. A comparison group of students who did not attend a visit were also recruited (n = 135). The impact of entering and learning about the hospital, and a conversational exchange with current residents was associated with a significant reduction in negative stereotypes and fear and an increase in compassion and motivation to help. The findings support the use of contact-based educational visits to change negative attitudes and responses towards patients with forensic and mental health histories.

Containing Chaos: A Self-Reflection of a Final Year Medical Student’s Elective in a High Security Psychiatric Hospital

IntroductionThroughout training, medical students are often only exposed to a limited selection of psychiatric specialities, predominantly general adult inpatient settings. This medical student had the opportunity to undergo a placement at a high security forensic hospital. With only three such hospitals in England, this is an environment that few students and even qualified doctors have been able to experience. In this presentation, the author will explore their prior expectations, key skills gained, and surprising realisations that made the elective highly valuable.ObjectivesTo reflect on the skills learned and revelations made during the elective period and share these as a presentation.MethodsThe author completed a 6-week placement at Ashworth High Security Psychiatric Hospital. He then reflected on his experiences.ResultsThis placement allowed the development of a range of skills and personal discoveries. The skills included enhanced personal safety awareness, improved use of varied communication styles, and de-escalation and management techniques with higher risk patients. The main finding was the fine line between Ashworth’s patients and mainstream society, and how easily these two entities can overlap. Carl Jung spoke of a ‘shadow’ that must be integrated, and the humanity within each patient made this philosophical concept a sobering reality.ConclusionsHigh security placements are valuable educational opportunities and teach important skills, not often found in the current medical school curriculum. These placements offer the transferable communication and interpersonal skills essential in any budding psychiatrist, and also provide a vital environment for self-reflection and personal growth.DisclosureNo significant relationships.

The influence of changes in clinical factors on high-security forensic custody dispositions.

The demand for forensic psychiatric beds is increasing, while many individuals are "stuck" in the system. Index offense severity and other legal considerations are associated with longer forensic stays but factors amenable to change such as symptoms of mental illness and aggression may also influence forensic decisions. We examined forensic review board decisions over time among 89 men admitted to a high-security forensic hospital. Almost half received a disposition to remain at their first hearing. Overall, dispositions were not associated with violence risk. The odds of a disposition to remain were higher for men with more in-hospital assaults and higher scores on a measure of clinical factors. Dispositions changed over time and this change was sensitive to clinical factors. We conclude that decisions were consistent with a cascading system of loosening security over time. Further longitudinal research following large samples through the forensic system is recommended.

Privacy and safety: Issues of dual compliance in high-secure and other forensic psychiatric hospitals

Health care organizations are obligated to provide safe and effective treatment to their patients and also protect the safety of their workers. This paper analyzes the tensions arising from legislative regimes that, respectively, protect privacy and workplace safety, using a large, tertiary high-secure forensic psychiatric hospital in Ontario, Canada, as an example. In Ontario, the Personal Health Information Protection Act (PHIPA) prohibits personal health information (PHI) from being disclosed to individuals who fall outside the “circle of care,” including nonclinical employees who have direct involvement with patients and may be at risk of violence. PHIPA permits the disclosure of information where there is a risk of violence, but the statute's scheme for privacy protection was not designed to address, and may not be compatible with, the operations and requirements of high-secure forensic and other psychiatric hospitals. At the same time, the Occupational Health and Safety Act (OHSA) creates a regulatory framework that sets health and safety standards, including an employer's duty to disclose the risk of violence. OHSA prosecutions and proceedings demonstrate how these duties have been enforced against psychiatric hospitals. We examine this regulatory backdrop, explaining that PHIPA provides little guidance to psychiatric hospitals, where the risk of violence is elevated. We also discuss issues of dual compliance that arise from a hospital's legal obligations under PHIPA and OHSA. Finally, we turn to the ongoing clinical and operational challenges, suggesting strategies for increasing staff safety. These include strengthening the therapeutic alliance and providing patients with the option of consenting to disclosure of PHI to those outside the circle of care.

Olanzapine long-acting injection, discontinuation rates and reasons for discontinuation: 10 years' experience at a UK high-secure hospital.

Background:Olanzapine pamoate has been shown to be an effective second-generation long-acting injection. Its popularity has possibly been adversely affected by the rare incidence of post-injection syndrome (PIS) and the associated requirement to monitor for 3 h after each injection.Objective:This study aimed to collect and present data on the use of olanzapine long-acting injection (OLAI) over a 10-year period in a high-security forensic hospital in South East England.Design:This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. As per hospital Trust guidelines, patient consent to access of hospital records was presumed unless explicitly withdrawn.Method:All patients prescribed OLAI between the years 2009 and 2019 were identified. Data collected included date that OLAI was started, stopped, dose range, side effects and concomitant medication.Results:Of 88 patients who were started OLAI, 45 (51%) continued at month 24. At 60 months, 22 of 70 (31%) patients for whom data were available continued with OLAI. Over 60% of continuers were on higher than recommended doses. Of almost 5000 injections administered, there was 1 episode of PIS.Conclusion:OLAI is an effective treatment for schizophrenia and schizoaffective disorder, especially when used in patients have been able to tolerate the drug and were stabilised on it for 24 months. In over half the patients who continued OLAI, the doses were higher than that recommended by the manufacturer. The incidence of PIS in this study was very low in comparison with other studies.Registration code:2049

An audit into the management of COVID-19 in a high security psychiatric hospital

AimsComprehensive and timely data collection during a pandemic is crucial in developing guidelines and policy as well as evaluating their effectiveness. In turn, this will improve planning for future incidents. While this is being undertaken at a national level by Public Health England, more specific information as it relates to psychiatric care is important in understanding the neuropsychiatric, psychological and social effects of the pandemic. The management of patients with COVID-19 presents a unique challenge in inpatient psychiatry settings both in terms of diagnosis and treatment. This is perhaps greater still in forensic settings due to the increased risk of violence and aggression. This audit aimed to firstly assess the consistency of local practice to national guidance from Public Health England. Secondly, it aimed to describe the clinical management of suspected and confirmed cases of COVID-19 in this high security forensic hospital and how readily broad, national guidance can be implemented in this unique setting. We present an audit with three cycles, one from each wave of COVID-19 in England during 2020.MethodThis was a retrospective audit in a high secure forensic psychiatry hospital in the United Kingdom, into the investigation and management of suspected and confirmed cases of COVID-19 compared to national guidelines from Public Health England. It includes three cycles, one undertaken in each national wave of COVID-19 in England in 2020.ResultTen patients have been included in cycle 1, 12 in cycle 2 and 21 in cycle 3 as those where COVID-19 was a considered diagnosis. SARS-CoV-2 was detected in one patient in cycle 1 and 12 patients in cycle 3. All patients recovered, most of whom remained on-site with supportive care in self-isolation on a dedicated ward for positive cases. Three patients required additional treated with oral antibiotics and dexamethasone, one of whom required admission to the local general medical hospital for continuous supplemental oxygen.ConclusionThis is the first study to describe the management of the novel COVID-19 pandemic in a high security forensic psychiatry hospital and how readily national guidance can be implemented in this unique setting. Hospital practice at identifying suspected cases and the management of confirmed cases of COVID-19 was shown to be consistent with national guidance. It also allowed for clinicians to exercise their judgement about testing for atypical cases and for repeat testing where appropriate.

An audit into the management of diabetes mellitus at Broadmoor Hospital

AimsDiabetes mellitus confers a twofold excess risk of cardiovascular disease - the leading cause of premature mortality in those with severe mental illness. Inpatients in forensic settings often have more severe, enduring and treatment-resistance forms of mental illness, sometimes necessitating combinations of prescribed antipsychotics. This audit aimed to assess adherence to National Institute for Health and Care Excellence (NICE) guidelines NG28 titled “type 2 diabetes in adults: management” and summarise the metabolic parameters of those with diabetes mellitus at Broadmoor hospital.MethodThis was a retrospective audit in a high secure forensic psychiatry hospital in the United Kingdom, into the management of patients with diabetes mellitus compared to guidance from NICE (NG28).ResultWe report data from over 30 inpatients (out of approximately 200) at a high secure forensic psychiatry hospital with a diagnosis of type 2 diabetes mellitus across two audit cycles. This audit identified improved adherence to national guidance regarding six monthly monitoring of HbA1c but with less than 50% of such patients having an HbA1c at or below the recommended target. This is in addition to high rates of other metabolic disorders such as obesity, dyslipidaemia and hypertension and a mean QRISK3 score that was markedly higher than a healthy person with the same age, sex, and ethnicity. There was a prevalence of background diabetic retinopathy of 8%, diabetic nephropathy of 5.4%, no recorded cases of diabetic neuropathy and a macrovascular disease prevalence of 5.4%. There were no new diagnoses of microvascular or macrovascular disease between audit cycles. One of the key changes between audit cycles was the recruitment of a dietician to the hospital. By the time of undertaking the second audit cycle, 23 patients had documented evidence of having been offered a referral to the dietician.ConclusionThis audit highlighted the marked cardiovascular risk in patients with type 2 diabetes mellitus at a high secure forensic psychiatry hospital. This includes suboptimal control of blood pressure, lipid profiles and HbA1c that increases the risk of premature mortality in these patients with severe mental illness. Wider, cultural changes in practice need to be implemented to improve the metabolic health of patients in the long-term inpatient setting of Broadmoor Hospital. This includes prescribers avoiding the most diabetogenic antipsychotics where possible, increasing the provision of sugar-free options at the on-site shop, examining the proportion of carbohydrate-rich foodstuffs in the shop and understanding the characteristics of its heaviest purchasers, and continued coordination between primary care and ward teams to support patients in making sustained changes to improve their metabolic health.

Vitamin D deficiency in a high secure forensic psychiatry hospital: A clinical audit and service evaluation

AimsTo assess concordance with guidelines on monitoring vitamin D levels and prescribing prophylaxis or replacement. To assess the association between the implementation of local guidelines and prevalence of vitamin D deficiency.BackgroundVitamin D deficiency is associated with various adverse health outcomes including osteoporosis, fractures and myalgia. Most recently, vitamin D deficiency has been hypothesised as a risk factor for severe COVID-19 infection. Risk factors for vitamin D deficiency include incarceration, ethnicity, diet and a diagnosis of psychiatric disorder. Vitamin D deficiency is known to be prevalent among individuals within forensic mental health institutions.Local Trust guidelines advise that vitamin D levels should be checked within one-month of hospital admission, followed by checks at three-monthly intervals. Recommendations for prescribing depend on patients’ vitamin D levels; deficient (&lt;25nmol/L), insufficient (25 &lt; 50nmol/L) or adequate (50-150nmol/L). We assessed concordance with these guidelines at Broadmoor Hospital, UK.MethodMedical records, laboratory results and drug charts were assessed for a total of 75 patients across 15 wards. Data were collected using a standardised audit tool, including; date of admission, admission vitamin D level, most recent vitamin D level and the dose and frequency of vitamin D prescribed.Result76.4% of patients had their vitamin D levels checked within one month of admission. 66.7% of patients had their vitamin D checked within the last 3 months. For patients with an admission vitamin D level recorded, 43.6% had deficient vitamin D levels, 43.6% had insufficient levels and 12.7% had adequate levels. For patients with a more recent serum vitamin D level, 14.5% had deficient levels, 38.7% had insufficient levels and 46.8% had adequate levels. For patients with a documented serum vitamin D level, 21.4% were prescribed the correct dose, 22.9% were under-dosed, 14.3% were over-dosed and 41.4% received no dose where guidelines suggested they should.ConclusionComparison of admission and most recent vitamin D levels suggests a general improvement in prevalence of vitamin D deficiency associated with the implementation of local guidelines. However, we identify significant areas for improvement. A substantial proportion of patients lacked admission or regular monitoring of vitamin D levels and a substantial proportion of patients were under-dosed or received no dose where guidelines suggested they should have. We propose that better concordance with guidelines may improve clinical outcomes further. This may prove especially important during the COVID-19 pandemic, given a potential association between vitamin D deficiency and severity of respiratory infection.

Exploring High Secure Forensic Patients’ Experiences of Familial Support: An Interpretative Phenomenological Analysis

Research has identified positive relationships between familial support and outcomes for forensic mental health patients. Such support has been linked to reduced recidivism, improved mental health and increased prosocial behavior. Whilst some studies have explored families’ experiences of providing such support, there is a paucity of research exploring patients’ narratives. Using Interpretative Phenomenological Analysis, the current study interviewed patients at a high secure forensic hospital and asked questions about their experiences of familial support. Results indicated four superordinate themes; Connection, Growth, Power, and Ambivalence. These results are discussed in relation to existing findings and clinical implications. Areas for future research are suggested.

Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital.

Objective:Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer.Methods:A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes.Results:Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient’s had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion.Conclusion:Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.

Outcome measures of risk and recovery in Broadmoor High Secure Forensic Hospital: stratification of care pathways and moves to medium secure hospitals.

Placements within high secure forensic hospitals consist of wards providing various different levels of relational security. They should form a coherent pathway through secure care, based on individual patient risks and needs. Moves to less secure wards within high secure forensic hospitals and moves on to lower secure hospital settings have rarely been systematically studied. The aim of this study was to ascertain if placements within Broadmoor High Secure Hospital and moves from Broadmoor to medium secure hospitals corresponded to measures of violence risk, programme completion and recovery. A 13-month prospective cohort study was completed. Patients (n = 142) were rated at baseline for violence risk (Historical, Clinical and Risk - 20), therapeutic programme completion and recovery (DUNDRUM tool) and overall functioning (Global Assessment of Functioning). Placements on the care pathway and moves on to medium secure hospitals were observed. Placements on the care pathway within the high secure hospital were associated with dynamic violence risk (F = 16.324, P<0.001), therapeutic programme completion (F = 4.167, P = 0.003), recovery (F = 2.440, P = 0.050) with better scores on these measures being found in the rehabilitation wards and the poorest scores on the highest levels of dependency. Moves to medium secure hospitals were associated with better scores on dynamic risk of violence (F = 33.199, P<0.001), therapeutic programme completion (F = 9.237 P<0.001), recovery (F = 6.863, P = 0.001). Placements within Broadmoor Hospital formed a coherent pathway through high secure care. Moves to less secure places were influenced by more than reduction in violence risk. Therapeutic programme completion and recovery in a broad sense were also important.

Inpatient violence in forensic psychiatry: Does change in dynamic risk indicators of the IFTE help predict short term inpatient violence?

Inpatient violence is a form of recidivism in forensic psychiatric treatment and is stated as an adverse outcome of treatment and a predictor for recidivism after release from the institution. Dynamic Risk Indicators (DRI) are critical key indicators that can predict inpatient violence, but little is known about the effects of change in DRI during forensic psychiatric treatment on the prediction of inpatient violence. This study examines the effects of change in DRI on the prediction of short-term inpatient violence using the Instrument for Forensic Treatment Evaluation (IFTE).A group of 96 patients is followed from entering a high secure forensic hospital until their fifth measurement approximately three years later. The outcome measure is defined as any inpatient violence six months after measurement five. Repeated measures are used to study whether there was a difference in change in DRI between the group of patients who did or did not committed inpatient violence. Binary logistic regression is used to establish the extent to which changes in DRI add to the predictive power of the last measurement.At the group level, the extent of change in DRI did not discriminate between the two patient groups. A large part of the 96 patients already scored low on DRI when entering the hospital and did not (need to) change. At all five measurements violent patients had significant higher scores on DRI than nonviolent patients. Logistic regressions showed that the last measurement predicts inpatient violence sufficiently, the change in DRI during the first four measurements did not contribute to this prediction.The change in dynamic risk indicators does not help to predict short term inpatient violence. The last measurement is the most practical predictor for short term inpatient violence, but because of the dynamic nature of these indicators it is necessary to frequently monitor these indicators to detect imminent risks.

Development of forensic normative data for the WAIS-IV

PurposeThe Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV) (Wechsler, 2008) is a cognitive assessment that is often used in secure forensic settings, however it has not been normed on this population. The purpose of this paper is to develop forensic normative data.Design/methodology/approachPatient files in a high secure forensic hospital were reviewed in order to obtain completed WAIS-IV (Wechsler, 2008) assessments and scores from the five indexes (verbal comprehension, perceptual reasoning, working memory, processing speed and full scale intelligence quotient (FSIQ)). This included reviewing patient files from all directorates, including male mental health, male learning disability, male personality disorder and the women’s service, yielding a sample size of n=86.FindingsThe qualitative descriptors obtained across the hospital ranged between extremely low and superior. The learning disability service scored significantly lower than the mental health and personality disorder services in verbal comprehension index, perceptual reasoning index, working memory index and FSIQ, and significantly lower than the mental health, personality disorder and women’s services in processing speed index. Mean scores from this study were significantly lower in comparison to those from the UK validation study (Wechsler, 2008).Practical implicationsThe significant difference between scores from the current study and those from the UK validation study (Wechsler, 2008) highlights the need to have appropriate normative data for forensic populations. Clinicians should consider interventions that may serve to increase cognitive function, such as cognitive remediation therapy.Originality/valueWhilst several special group studies have previously been conducted, this study is the first to develop forensic normative data for the WAIS-IV (Wechsler, 2008). Whilst the sample size was relatively small with limited female participants, the data collated will enable clinicians working in forensic establishments to interpret their assessments in light of this information.