High Secure Psychiatric Hospital Research Articles

Developing ward social climate and sense of community within a high security forensic psychiatric service: Evaluating a sense of community and social climate intervention

ABSTRACT Inpatient ward social climate and sense of community can influence the recovery and care experiences of forensic mental health patients. This research evaluated an intervention designed to improve social climate and sense of community within a high-secure psychiatric hospital in the UK. The intervention was offered across six wards: two wards received the full intervention, two received the partial intervention, and two received no intervention (control). Social climate and sense of community were measured prior to the start of the intervention 6 and 18 months into the intervention, using the Essen Climate Evaluation Schema and the Sense of Community Index-2. Changes in frequency of disruptive behaviour were also monitored across time points. Results revealed that the full and the partial intervention groups reported greater feelings of social climate than the control group. This effect was also observed across time points, with higher social climate scores in the full and partial intervention groups compared to control group at 6 and 18 months. Furthermore, social climate scorespredicted a significant reduction in frequency of incidents across time in the full intervention. These findings provide longitudinal evidence of the importance of developing ward social climate and sense of community within forensic inpatient settings.

Robert Bluglass: forensic psychiatrist who called for the closure of high security psychiatric hospitals

Robert Bluglass: forensic psychiatrist who called for the closure of high security psychiatric hospitals

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 effects of COVID-19 on self-harm in a high-secure psychiatry hospital

Purpose Self-harm, including death from suicide, remains a significant public health challenge. The prison population is known to be a high-risk group for self-harm and suicide. The purpose of this study is to explore the trends in the frequency of self-harm over the course of the COVID-19 pandemic within a high-secure hospital. The authors hypothesised that the pandemic could adversely affect the mental health of patients, which could increase the rates of self-harm. Reasons for changes in the frequency of self-harm and the strategies used in response to the pandemic were also investigated. Design/methodology/approach This paper encompasses findings from a quality improvement project that investigated self-harming behaviours from February 2020 to February 2021 in a high-secure psychiatric hospital. Incidents of self-harm were recorded based on the hospital’s ward structure. Data was collected on the incidence of self-harm rates over the COVID-19 pandemic, with a focus on how the pandemic may have had an effect on self-harm. Findings This paper found an increase in the incidents of self-harm during the initial stages of the pandemic. The first national lockdown period yielded a rise in self-harm incidents from pre-COVID levels. The frequency of self-harm reduced following the first lockdown and returned to pre-COVID levels. The authors explored the psychological effects of COVID, isolation, interpersonal dynamics and changes in the delivery of care as reasons for these trends. Practical implications This study demonstrates the substantial challenges of the COVID-19 pandemic to secure psychiatric services. Having an awareness of how the pandemic can impact on self-harm is important, as it allows the correct balance of restriction of our patients’ liberty to a degree deemed necessary to control the pandemic and the delivery of effective patient care. The key clinical implications include the importance of direct face-to-face patient contact, effective communication, therapeutic interventions and activities, the psychological impact of quarantine and the influence the pandemic can have on an individual’s function of self-harm. Originality/value This paper is the first, to the authors’ knowledge, to explore the impact of COVID-19 in a high-security psychiatric hospital. The authors also explore possible explanations for the changes in the trends of self-harm and include the consideration of strategies for improving the prevention and management of self-harm in high-secure settings during a pandemic.

An audit into the use of psychotropic medications in patients with autism spectrum disorder in a high security psychiatric hospital

AimsAutism Spectrum Disorder (ASD) is a common neurodevelopmental disorder associated with difficulties in social communication and language development, preoccupations, a need for routine, sensory sensitivities and emotional dysregulation. People with autism who have violently offended may be prescribed psychotropic medications to treat comorbidities, or off-license to manage aggressive or challenging behaviours. However, the evidence base for their use remains scarce.MethodThis was a retrospective audit at Broadmoor Hospital, a high security psychiatric hospital in the United Kingdom, into the safe and appropriate prescribing of psychotropic medicines in those with an ASD compared to guidance from the National Institute for Health and Care Excellence (CG142): “Autism spectrum disorder in adults: diagnosis and management”. This first cycle was undertaken during May and June 2020 and included all patients with a confirmed or equivocal diagnosis of ASD in the preceding five years.ResultA total of 22 participants were included in this study. Of these, 17 participants had a confirmed diagnosis of ASD and five participants had a suspected diagnosis of ASD, but without formal confirmation with neurocognitive testing. A total of 13 (76.5%) participants with confirmed ASD were prescribed antipsychotic medication, nine of whom had an established comorbid mental disorder with psychotic symptoms. Of the remaining four, three had a diagnosis of a personality disorder. Three participants in this study had a confirmed diagnosis of ASD without any additional comorbid mental health diagnoses. No patients were prescribed psychotropic medicines for the core symptoms of ASD. The specific documentation of off-license use of antipsychotic medicines in those without a diagnosis of a psychotic disorder was poor. This was not recorded in any such participant in the preceding 12 months.ConclusionThis audit highlighted that dual diagnoses of ASD alongside non-affective psychosis and personality disorder are over-represented in this high security setting. The NICE clinical guidelines CG142 guidelines state that “antipsychotic medications should only be used for behaviour that challenges if …. the risk to the person or others is very severe”. By definition, all patients admitted to high security are deemed to be a grave and imminent risk to the public. Psychotropic medicines may therefore be clinically indicated at a much earlier stage than in community patients, instigated alongside appropriate psychosocial interventions and treatment of comorbid conditions. It may be that catered guidelines need to be formulated to support the safe and appropriate prescribing of psychotropic medicine in forensic settings.

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.

Wechsler Adult Intelligence Scale Full Scale IQ of Male Admissions to a High Secure Psychiatric Hospital Over Six Decades

The present study describes the Wechsler Adult Intelligence Scale (WAIS) full scale IQ (FIQ) of admissions to one UK High Secure Psychiatric Care hospital. WAIS IV comparative data and the FIQ of admissions from the 1960s to the 2010s are presented (n = 639). Results suggest 75% of current admissions have FIQs within the ‘low average’ and ‘extremely low’ classifications, with significant discrepancies between composite scales being common and processing speed being the most compromised area of cognitive functioning. A one standard deviation decline in FIQs of admissions since the 1960s to the 2010s is also present. The results are discussed in terms of the changing clinical presentations of admissions, along with research and clinical implications.

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.

Examining the relationship between neuropsychological functioning assessed during admission to a high secure psychiatric care hospital and vulnerability to long-term segregation

PurposeThis paper aims to examine the relationship between neuropsychological functioning as assessed following admission to a high secure psychiatric care (HSPC) hospital and subsequent time spent in long-term segregation (LTS). Evidence from forensic populations suggests neuropsychological functioning difficulties can increase vulnerability to interpersonal violence. However, the impact of this relationship on restrictive interventions used in these settings is poorly understood.Design/methodology/approachThis study quantitatively examined the neuropsychological profiles of 80 male HSPC patients as assessed during routine admission assessments, comparing data against any subsequent LTS duration during a one-year period, and a non-LTS control (n = 27).FindingsAnalysis found individuals who were willing and able to complete a routine neuropsychological admissions assessment spent significantly less time in LTS than those unable to complete the assessment. Performance within a test of novel problem solving (Key Search Test) was significantly worse in the LTS group than controls. Performance within a visual memory task (Immediate Recall section of the Rey Complex Figure Test) significantly correlated with LTS duration. Additional findings suggest the absence of self-reported planning difficulties as measured by a Dysexecutive Questionnaire (DEX) negatively correlated with LTS duration, while self-reported restlessness was positively correlated with LTS.Practical implicationsThis has implications for early assessment of LTS risk and potential use of cognitive interventions to reduce the use of restrictive practices.Originality/valueThe results suggest some aspects of neuropsychological performance as assessed during admission to a HSPC hospital appear to be related to subsequent time spent in LTS.

Care quality commission inspections of high-security hospitals

PurposePatients detained in high-security psychiatric hospitals are particularly vulnerable to excessive restrictions and exploitation. In the UK, the care quality commission (CQC) monitors and regulates forensic healthcare provision. The purpose of this study is to identify key concerns highlighted in CQC inspection reports of the three high-secure hospitals in England between 2010 and 2018.Design/methodology/approachIn this qualitative study, 49 CQC inspection reports from three high-secure hospitals were subjected to thematic analysis.FindingsFive central themes emerged: staffing and management; restrictive practice; physical environment and ward atmosphere; patients’ needs and involvement in their care; and legal and statutory matters. There was some variation in the overall quality of care between the hospitals. Positive staff–patient interactions and good practice in assessing and delivering care were consistently observed. However, enduring staff shortages within each hospital were experienced negatively and sometimes co-occurred with concerns over restrictive practices, poor care-plan procedure and inadequate legal documentation. Over time, Rampton and Broadmoor Hospitals appeared to worsen with regard to staffing levels, staff morale and management involvement. While services progressed over time in providing patients with access to advocacy and information concerning their rights, in some recent inspections it remained unclear whether patients were adequately involved in the care-plan process.Practical implicationsThese findings provide preliminary indicators for areas requiring further attention from policymakers, clinicians and advocates.Originality/valueThis study appears to be the first systematic analysis of key concerns expressed in CQC reports of English high-security hospitals.

Evaluation of autism awareness training provided to staff working in a high secure psychiatric care hospital

PurposeThe purpose of this paper is to evaluate autism awareness training provided to staff working in a high secure psychiatric care (HSPC) hospital.Design/methodology/approachAn online survey of staff views who had completed an autism awareness training day.FindingsAll staff who completed the evaluation questionnaire reported that an autism awareness training day had been useful and had increased their knowledge of how to work with individuals who have autism. However, most staff also reported that one day was not long enough and that more case discussion would have been helpful. Although most staff also reported that autism awareness training should be mandatory, motivation to attend such training was considered important. In terms of the number of staff who had completed the training, whilst a wide range of staff groups had attended training, only a minority had done so, with the number of staff completing the training each year remaining relatively constant over a five-year period.Research limitations/implicationsWithin the context of promoting Enabling Environments in forensic settings and the recent government consultation paper exploring whether autism awareness training should be mandatory for all those working in health care, further investigation is required into how to increase staff motivation to attend autism awareness training and to explore how it is used during everyday work with patients.Originality/valueAs an initial evaluation of optional autism awareness training delivered in HSPC, the project offers some valuable information in terms of the number of staff who attend such training, what they find useful and how it might be improved for this setting.

Understanding motives for aggression in forensic psychiatric patients: a preliminary study

ABSTRACTThe primary aim of this study was to explore motivations underpinning aggression among men detained within conditions of high security. Thirty men residing at a high secure psychiatric hospital completed self-report measures, including the Aggression Motivation Questionnaire, Revised EXPAGG and Barratt Impulsiveness Scale-IIr. The Historical items of the Historical, Clinical and Risk-Management (HCR-20) and the Psychopathy Checklist-Screening Version were rated. A subsample of participants agreed to complete a functional assessment on an aggressive incident that had occurred during their placement (n = 9). Increased psychopathy and impulsivity, and the presence of historical risk items were predicted to associate with higher levels of both aggression motivation and beliefs supportive of aggression. Young age at first violent incident and personality disorder related positively to aggression motivation. Thematic analysis conducted on the functional assessments identified social recognition, emotion regulation, communication and protection as functions underpinning aggression. Results are discussed with regards to their implication for violence treatment and assessment, with a focus on motivation recommended.

The Relationship Between Ward Social Climate, Ward Sense of Community, and Incidents of Disruptive Behavior: A Study of a High Secure Psychiatric Sample

Assaults and seclusions within the UK obstruct patient recovery, and carry a combined UK cost of £106 million a year. Research has identified low ward social climate and lack of sense of community as potential factors that contributes to disruptive behavior. The current study investigates the relationship between self-reported sense of community and social climate scores with incidents of disruptive behavior (i.e., assaults and seclusions) within a UK high security psychiatric hospital. Findings reveal that both social climate and sense of community predict incidents of disruptive behaviour. This study suggests that both factors should be monitored in high security hospitals.

Night-time confinement and the practice of realistic medicine.

SummaryNight-time confinement is the practice of routinely locking patients in their rooms at night unless there is a contrary clinical indication. It is used in high-secure psychiatric hospitals. This article argues in favour of this practice on the basis of realistic medicine, an individual human rights based approach, the principles of mental health legislation in Scotland and England and cost effectiveness. This is not an academic debate. There is a real danger that those advocating against night-time confinement, if successful, will at best make little difference to the lives of our patients as they sleep, and at worst may hugely impoverish their lives because of reduced daytime activities.Declaration of interestL.T. is Medical Director at The State Hospital. Night-time confinement is used within this setting.

Predictive power of the DASA-IV: Variations in rating method and timescales.

This project evaluated the predictive validity of the Dynamic Appraisal of Situational Aggression - Inpatient Version (DASA-IV) in a high-secure psychiatric hospital in the UK over 24hours and over a single nursing shift. DASA-IV scores from three sequential nursing shifts over a 24-hour period were compared with the mean (average of three scores across the 24-hour period) and peak (highest of the three scores across the 24-hour period) scores across these shifts. In addition, scores from a single nursing shift were used to predict aggressive incidents over each of the following three shifts. The DASA-IV was completed by nursing staff during handover meetings, rating 43 male psychiatric inpatients over a period of 6months. Data were compared to incident reports recorded over the same period. Receiver operating characteristic (ROC) curves and generalized estimating equations assessed the predictive ability of various DASA-IV scores over 24-hour and single-shift timescales. Scores from the DASA-IV based on a single shift had moderate predictive ability for aggressive incidents occurring the next calendar day, whereas scores based on all three shifts had excellent predictive ability. DASA-IV scores from a single shift showed moderate predictive ability for each of the following three shifts. The DASA-IV has excellent predictive ability for aggressive incidents within a secure setting when data are summarized over a 24-hour period, as opposed to when a single rating is taken. In addition, it has moderate value for predicting incidents over even shorter timescales.

Providers' competencies positively affect personal recovery of involuntarily admitted patients with severe mental illness: A prospective observational study.

There is limited research on the patient-provider relationship in inpatient settings. The purpose of this study was to measure the effect of mental healthcare providers' recovery-promoting competencies on personal recovery in involuntarily admitted psychiatric patients with severe mental illness. In all, 127 Dutch patients suffering from a severe mental illness residing in a high-secure psychiatric hospital reported the degree of their personal recovery (translated Questionnaire about Processes of Recovery questionnaire (QPR)) and the degree of mental healthcare providers' recovery-promoting competence (Recovery Promoting Relationship Scale (RPRS)) at two measurement points, 6 months apart. (Mixed-effects) linear regression analysis was used to test the effect of providers' recovery-promoting competence on personal recovery, while controlling for the following confounding variables: age, gender drug/alcohol problems, social relationships, activities of daily living, treatment motivation and medication adherence. Analyses revealed a significant positive effect of providers' recovery-promoting competencies on the degree of personal recovery ( t = 8.4, p < .001) and on the degree of change in personal recovery over time ( ts > 4, p < .001). This study shows that recovery-promoting competencies of mental healthcare providers are positively associated with (a change in) personal recovery of involuntarily admitted patients. Further research is necessary on how to organize recovery-oriented care in inpatient settings and how to enhance providers' competencies in a sustainable way.

An evaluation of the use of electroconvulsive therapy in a United Kingdom high secure psychiatric hospital

IntroductionElectroconvulsive therapy (ECT) is an effective NICE-approved treatment for severe depression, treatment-resistant mania and catatonia; the Royal College of Psychiatrists’ (RCPsych) guidelines also support its use fourth line for treatment-resistant schizophrenia.ObjectivesEvaluate the use of ECT at Broadmoor High Secure psychiatric hospital, focusing on the indications for its prescription and patients’ capacity to consent.MethodAnalyse case records of all patients who received ECT, and of all patients referred for Second Opinion Appointed Doctor (SOAD) certified ECT treatment under Section 58 of the Mental Health Act 1983 (MHA) due to incapacity, between 01.09.11 and 30.07.15.ResultsAll patients lacked capacity to consent to treatment during this time. Thirty-three referrals were made to the SOAD service for 15 patients, and of these 30 resulted in certification (T6) of which 10 were not subsequently used. Improvements in mental state and agreement to take clozapine were common reasons for T6s either not being certified or used. Urgent treatment under Section 62 of the MHA was employed 7 times for 4 patients during this period. Of the referrals to the SOAD service, 25 were for treatment-resistant schizophrenia, 5 for mania, 3 for catatonia and none for depression.ConclusionsThose patients requiring ECT within this population tended to be the most unwell and all lacked the capacity to consent to it. The majority (76%) of patients receiving ECT at Broadmoor do so outside of NICE (but within RCPsych) guidelines. ECT may be an effective strategy for promoting compliance with clozapine.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Factors influencing the rate of incidents in a United Kingdom high secure psychiatric hospital: Weekend, ward round and diagnostic effect?

IntroductionBroadmoor is a high secure psychiatric hospital divided into personality disorder (PD) and mental illness (MI) pathways. Whenever an incident occurs, it should be recorded. To better understand which factors influence the rate of incidents, such as diagnosis or intervention by medical and psychological staff, we examined the difference in the number of incidents recorded on weekdays versus weekends, ward round (WR) versus non-WR days and the PD versus MI pathways.MethodAll incidents recorded over a one-year period (3.11.2014–2.11.2015) were examined. Extraneous incidents were excluded, leaving subgroups of “aggressive” (physical and verbal) and “physical” (excluding verbal) incidents which were analysed. Data were adjusted for the difference in number of beds in each pathway.ResultsOf the 2369 incident reports included, more were recorded per day on weekdays than weekends, with little difference on WR versus non-WR days. The rates of both types of incidents were similar on both PD and MI admission wards, although the rate of “physical” incidents was 2.6 times higher and “aggressive” incidents 3.3 times higher in PD compared to MI rehabilitation wards.ConclusionThe findings suggest the presence of medical and psychological staff during the week, and possibly the requirements they place on patients, may increase the rate of incidents within the hospital. Despite comparable rates on admission, MI rehabilitation wards have far fewer incidents than PD rehab wards, which may reflect the more intractable nature of PD versus MI. More work is required to confirm these findings.Disclosure of interestThe authors have not supplied their declaration of competing interest.

An analysis of emergency leaves of absence from a United Kingdom high secure psychiatric hospital with a view to identifying ways to reduce their number

IntroductionEmergency leaves of absence (ELOAs) from high secure psychiatric care are both costly and increase the risk posed to staff, patients and the general public. ELOAs were analysed to identify whether greater on-site physical health provision could reduce their number, and quantify the potential financial saving to the trust to do so.MethodAll ELOAs from Broadmoor hospital between 15.5.15–14.11.15 were assessed by a team of psychiatrists and a GP to identify whether they were “avoidable”, “unavoidable” or “potentially avoidable” if measures were taken. For the “potentially avoidable” group, we then calculated the staffing cost of these LoAs to help ascertain whether these measures would be cost effective.ResultsThere were 30 ELOAs during the period assessed, costing £79,240 (Table 1). The table also shows which additional on-site services or training may have prevented these ELOAs, and the cost saving to the trust if they had.ConclusionsThe number of ELOAs from the hospital could be reduced by increased on-site physical health provision and training. This would improve the quality of care patients receive, as well as reducing both the cost to the trust and the risk posed to staff, patients and the general public. We must also consider the large potential cost and risks associated with a patient absconding from an ELOA.

Prognostic Factors for Length of Enforced Forensic Treatment with Special Focus on Personality Disorder

ABSTRACTThe predictive value of personality disorder (PD) on treatment length of offenders detained in high security psychiatric hospitals in the Netherlands was studied on 536 male patients (mean age 34.0 years, SD = 10.5, range: 18.0–68.8) with a 76.5% PD prevalence. Results showed that PD did not independently predict length of enforced treatment. A subgroup of patients with only PD and no comorbid major mental disorder had a shorter treatment length. This study has isolated separate factors that can shorten or prolong treatment and can provide a focus for both policy and (clinical) decision makers in the enforced treatment process.