High Secure Setting Research Articles

Physical Health and Activity of Inpatients under Forensic Mental Health Care: A Cross-Sectional Survey and Audit of Patients in a High Secure Setting in Queensland, Australia

Obesity and metabolic syndrome are disproportionately prevalent among people with mental disorders, particularly those subject to long periods of inpatient care where sedentary lifestyle and medication side effects can be compounding problems. This study reports on a cross-sectional survey of 28 patients under forensic mental health care in a high secure inpatient service in Queensland, Australia. The study comprises a file review, structured questionnaire and an interview, to evaluate the physical health and activity, as well as possible causes of low physical activity of these patients. Rates of overweight (50.0%), obesity (46.6%), and metabolic syndrome (39.3%) were very high within the study population. Mean waist circumference measurements were also high for both females (110.8 cm) and males (109.0 cm). Around one half of the study population (46.4%) did not meet the World Health Organization’s recommended levels of physical activity. Self-reported low levels of physical activity were significantly associated with the presence of comorbid medical illness (p = 0.007). Further research investigating the factors contributing to poor physical health and low activity levels within this population will support attempts to understand and address the physical health needs of this population.

Beyond the sentence: Shared reading within a high secure hospital.

Ashworth Hospital provides care for inpatients detained under the Mental Health Acts who present a danger to themselves or others. Rehabilitative interventions can help support the best outcomes for patients, their families, care providers, and society. The efficacy of weekly Shared Reading sessions for four patients with experience of psychosis and a history of self-harm was investigated using a 12-month longitudinal case series design. Session data were subjected to psychological discourse analysis to identify discursive strategies employed to accomplish social action and change over the duration of the intervention. Archetypes of interactional achievement across sessions emerged. Broadening of capacity to consider was demonstrated through increased hedging and less declarative language. Increased assertiveness was achieved through reduced generalisation marked by a transition from second-person plural pronouns to more first-person singular pronouns. Avoidance of expression and disagreement strategies diminished over time. In addition, heightened engagement was accomplished through the increased tendency to employ functionally related and preferred responses within adjacency pairs, which mirrored non-verbal communicative strategies. Shared Reading shows promise for promoting the interactional accomplishment for individuals within high secure settings, who are ready to undertake a recovery-related activity. Pathways of interaction should continue to be explored, with consideration to the current study's strengths and limitations. This study contributes to the understanding of efficacious reading study design and the interactional outcomes of therapeutic reading.

Understanding and Overcoming COVID-19 Vaccine Hesitancy & Anti-Vaccine Beliefs Within the High Secure Forensic Services

AimsThis is a cross-sectional service evaluation study of the vaccination programme within the high secure setting of Broadmoor hospital with a view of improving the quality of it's delivery. We aimed to establish patients views about COVID-19 vaccinations particularly if there are any themes as to why the patients choose/did not choose to receive the vaccine. This information will be used to help us understand how to overcome vaccine hesitancy and anti-vaccine beliefs.MethodsPatients across Eight wards were asked to participate in the study. 56 patients agreed to be administered the following semi-structured questionnaire by the doctors. 1.Have you had a COVID-19 vaccine?2.Do you think there any advantages to taking a COVID-19 vaccine? Yes/No. If you think there are any advantages, please write these3.Do you have any fears or worries about the COVID-19 vaccine? Yes/No. If you do have any fears or worries, please write these.The results of this were reviewed and put into the categories that are cited below.Results14 patients had no vaccination, 2 had one, 38 had two or more.34 patients said there were advantages, 13 said no advantages and 9 did not know. The themes of the advantages were established: Protects you from bad infection and symptoms (48), stops you from passing it on to others (3), blank (13), others (13) which included “Important to follow government guidelines, proven through history to work, it was offered, I'm more concerned with hepatitis, The doctor would have my best interests.”30 patients stated that they did have fears and 26 did not. Common themes established were; side effects (17), Not tested correctly/given too quickly (5), Blood clots (2), positive comments (2), blank (22), others (10), which included, “Interaction with medications, more fear about face masks, injecting humanity with something could kill them, infertile generation, Control the public, don't like injections and alter the DNA genome.” The common side effects of concern were “painful arm, fever and headache.”Conclusion68% of patients had 2 or more vaccinations across the 8 wards studied. The commonest advantages cited by 86% of patients was to protect themselves from serious illness. The commonest fears or worries were of side-effects that result from the vaccine, although 46% patients had no worries and 39% gave no explanation for fears or worries. The fears and worries appeared mainly related to vaccine hesitancy rather than fixed generalised anti- vaccine views.

The use of coercive measures in a high security setting in Belgium: Prevalence and risk factors

Coercive measures are often used in forensic psychiatric settings as a strategy to manage violent and other problematic behavior. Few studies have been published regarding the use of coercive measures in high security populations. This is the first empirical study on this subject in Belgium. The aim of the present study was to examine the prevalence rates of coercive measures in Flanders' two high security settings and to identify individual patient risk factors for being subjected to a coercive measure. The study included all patients (N = 654) who were admitted in the Forensic Psychiatric Centres of Antwerp or Ghent over a six-year period. Data on the use of coercive measures (seclusion, mechanical restraint, and chemical restraint) were registered prospectively. Several regression analyses were conducted with multiple independent variables. The results show that half of the population (49.4%) was subjected to at least one coercive measure during admission in one of the high security settings. A small subgroup of patients (6.6%) was the subject of half of all coercive measures (51.0%). Seclusion was the most frequently used coercive measure (48.3%), followed by chemical restraint (12.2%). The prevalence rate of mechanical restraint was very low (0.8%) compared to previous research in similar populations. Various individual risk factors were significantly associated with a higher use of coercive measures. Clinical implications are discussed and the importance of developing international standards on recording and reporting on coercive measures is highlighted.

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.

Audit on High Dose Antipsychotic Treatment (HDAT) Monitoring at Rampton Hospital

Aims•High Dose Antipsychotic Treatment defined as 100% of the maximum recommended dose in British National Formulary, either as single agent or in combination.•HDAT and poly-pharmacy may be linked to heightened mortality for psychiatric patients. The Committee on Safety of Medicines, Medicines and Healthcare Products Regulatory Agency recommended ECGs, electrolyte monitoring after each dose escalation, and 6 monthly intervals.•The Royal College of Psychiatrists in 2006 suggested some justifiable cases of temporary poly-pharmacy with careful monitoring.•This audit has been done in past to improve standards, especially in High Secure Setting where prescribing HDAT is a common practice•To audit adherence to “HDAT monitoring guidelines” including regular monitoring of bloods, physical observations and ECG , done after every dose escalation plus at every 6 months.•To monitor compliance with consent to treatment documentation including reasons of being on HDAT, documentation of physical health monitoring resultsMethod•All patients prescribed high dose antipsychotic (regular and as required) were identified by treating Consultants and also going through drug cards.•One year retrospective review of haematological, ECG and physical observations were identified through Electronic notesResult•6 % of patients received HDAT within Rampton Hospital in 2018(12 males’ vs 6 females).•All patients on Regular HDAT had yearly TFT done whereas only 71% had prolactin monitoring done.•Approximately 50-60% of patients had quarterly blood monitoring including glucose, electrolytes, lipids, liver function test and full blood count.•About 40% of patients had quarterly ECG monitoring recorded.•100% patients on regular HDAT had quarterly physical observation monitoring compared to 81% patients on HDAT (including PRN).•Consent forms were completed for all patients on HDAT. 85% patients on regular HDAT has the reasons for treatment documented in the notes compared to 100% patients on HDAT (including PRN).Conclusion•Improvement in monitoring of blood parameters and cardiac function (ECG) 40-60% as compared to 2014 audit (8% to 23%).•Yearly monitoring of TFTs and Prolactin also appeared better (100% and 71%) which was (88% and 72% in 2014).•Quarterly physical observations were recorded in 77% patients on regular HDAT in 2014 which improved to 100% in 2018.•There was slight difference for those who were on PRN (77% to 81%). All prescribers informed about results and reminded of recommended guidelines•Reaudit in 2021-22 to measure change in clinical practice in prescribing HDAT.

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.

Factors affecting high secure forensic mental health nursing workforce sustainability: Perspectives from frontline nurses and stakeholders.

WHAT IS KNOWN ON THE SUBJECT?: There are insufficient nurses to meet current demand for mental health care. This is an international concern. Within England, the impact of staff shortages on the quality of patient care in forensic high secure settings has been highlighted by the national regulatory body for hospitals. Forensic hospital nursing is a distinct specialism within mental health. Forensic nurses must negotiate the therapeutic, ethical and practical challenges of caring for high-risk patients in a locked environment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: There has been no previous study to ask frontline high secure forensic nurses, union representatives, senior nurses and workforce leads about what factors may be affecting recruitment and retention in their setting. As well as the specialized and challenging nature of the work, participants identified that workforce sustainability was affected by unequal working terms and conditions, the hospital locations and wider national factors, such as changes to how nurse training was funded. They also identified that some strategies that were employed to address workforce shortages, such as day-to-day movement of staff within the hospital and incentive packages for new recruits could be demotivating for established staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Forensic high secure nursing workforce strategies should include training, development and career pathways that are specific to the specialism and extend beyond preceptorship for newly qualified staff. There should be clear and equitable employment terms and conditions with remuneration packages that are consistent within and between organizations. Hospital managers should address the effect that movement of staff between wards may have on nurses' morale, therapeutic relationships and safety culture. ABSTRACT: Introduction There has been no previous study of stakeholders' views on recruitment and retention concerns in high secure forensic settings. Aim To identify factors affecting recruitment and retention in high secure hospitals, from the perspectives of stakeholders with experience in forensic mental health nursing. Method Framework analysis of data from fifteen interviews and three focus groups with frontline nurses, nurse leaders, recruitment leads and union representatives from three high secure hospitals in England. Results Six themes emerged from the data: (a) the unique nature of high secure nursing; (b) the impact of short staffing; (c) wider factors affecting the high secure nursing workforce; (d) the location; (e) staff being on different terms and conditions of work; (f) recruitment strategies. Discussion Multiple factors are likely to simultaneously affect high secure hospital recruitment and retention. Findings on the unique nature of high secure work reflect previous qualitative research. The themes of location, working terms and condition and recruitment strategies have not been previously identified in forensic nursing research. Implications for practice Employers should ensure that employment terms and conditions are equitable and consistent. Furthermore, hospital managers should address the effect that movement of staff between wards may have on morale and therapeutic relationships.

Toward a Tailored Model of Youth Justice: A Qualitative Analysis of the Factors Associated with Successful Placement in a Community-Integrated Facility

Community-integrated facilities provide security and care for justice-involved youth, minimizing risks, while allowing youth to build on protective factors within their community. Literature on the specific factors that determine appropriate placement in a community-integrated facility, versus a more restrictive high-security setting, is scarce. Current screening and assessment tools for youth are mostly applied after placement and mainly focus on the reoffending risk. The current paper explored which youth, who would previously have been placed in a high-security setting, could be successfully placed in a less secure community-integrated facility. Through qualitative analysis, based on the perspectives of professionals, youth and parents, the current paper identified six distinct domains to guide appropriate screening and outlines guidelines for policy and practice. These domains include: motivation to comply, short and long-term perspective, current offense context, crime history, safety and support from youth’s network, and mental health and intellectual abilities.

Barriers and facilitators to the effective de-escalation of conflict behaviours in forensic high-secure settings: a qualitative study

BackgroundViolent and aggressive incidents are common within mental health settings and are often managed using high-risk physical interventions such as restraint and seclusion. De-escalation is a first-line technique to manage conflict behaviours and prevent violence and aggression. There is limited research into the use of de-escalation in high-secure settings. This study investigated staff, patient and carer perspectives on the barriers and facilitators to using de-escalation for conflict behaviours.MethodsSemi-structured individual interviews (n = 12) and focus groups (n = 3) were conducted with eight patients, four carers and 25 staff members in a high-secure hospital in England. Interviews and focus groups were informed by the theoretical domains framework and were digitally recorded, transcribed verbatim and analysed using framework analysis and the COM-B behaviour change model.ResultsFour themes and 15 sub-themes (barriers and facilitators) were identified. Themes related to capabilities (building relationships: knowing the patient and knowing yourself), opportunities (filling the void: challenges within the high-security environment; dynamic relationships) and motivation (keeping everyone safe). Strong staff–patient therapeutic relationships underpinned by trust, fairness, consistency and an awareness of the trauma-aggression link were considered key to successful de-escalation. Specific psychological and interpersonal skills including empathy, respect, reassurance, sincerity, genuine concern and validation of the patient perspective are needed to achieve this. Barriers related to the physical environment; organisational resources, practices and systems; staff traumatisation; hierarchical and punitive attitudes towards patient care, and an insufficient understanding of psychiatric diagnoses, especially personality disorder. It was apparent across themes that fear, which was experienced by both staff and patients, was a driver for many behaviours.ConclusionsThis work has identified organizational and behaviour change targets for interventions seeking to reduce violence and restrictive practices through the use of de-escalation in high-secure hospitals. The potential for, and occurrence of, violence in such settings is high and leads to fear in patients and staff. The factors which promote fear in each group should be addressed in de-escalation training.

Perceptions of Restrictiveness in Forensic Mental Health: Do Demographic, Clinical, and Legal Characteristics Matter?

Where safe, forensic mental health systems should provide care in the least restrictive environment possible. Doing so can maximize patient autonomy and empowerment while minimizing unnecessary social disconnection and stigmatization. This study investigated whether patients' perceptions of restrictiveness were associated with demographic, clinical, and legal characteristics. The Forensic Restrictiveness Questionnaire (FRQ) was used to measure perceptions of restrictiveness in 235 patients in low-, medium-, and high-secure settings in England. The results showed that restrictiveness scores were significantly higher for patients who experienced an adverse event in the past week or were diagnosed with a personality disorder compared to those with a mental illness. A regression analysis suggested that only diagnosis was predictive of FRQ scores when controlling for perceptions of ward atmosphere and quality of life. Age, length of stay, ethnicity, level of security, legal section, and offence type were not associated with FRQ scores. Future research should investigate the roles that individual symptoms, insight into illness, mood, personality, and expectations of care have in influencing perceptions of restrictiveness.

Structured versus unstructured judgment: DUNDRUM-1 compared to court decisions

BackgroundCriteria to determine in which level of security forensic patients should receive treatment are currently non-existent in Belgium. Courts largely rely on the evaluations of the prison psychiatrists and psychologists to form their decision. None of the few available instruments – e.g., the DUNDRUM-1 – is currently used to provide structured clinical judgment when determining security level. MethodDUNDRUM-1 scores were collected for 150 forensic patients. Security levels according to DUNDRUM-1 assessment were compared to security levels as decided by the court. ResultsThere was little agreement between DUNDRUM-1 scores and proposals for secure care made by the court. The DUNDRUM-1 predicted eventual admission to a high security setting, but not a medium security setting. ConclusionThe DUNDRUM-1 is an instrument that can help clinicians and judges to make more reliable and transparent decisions regarding secure care. However, further research with regard to practical applicability is needed.

Not guilty by reason of insanity: clinical and judicial profile of medium and high security patients in Belgium

ABSTRACTUnder Belgian law, offenders deemed to lack criminal responsibility because of insanity receive mandated treatment under the internment law. Population profiles of these forensic patients (‘internees’) are, however, very scarce. In this study, we analysed the demographic, clinical and judicial profile of a large sample of Belgian internees admitted to a secure setting. In addition, differences between internees admitted to a medium versus a high security setting were investigated. Belgian internees were characterised by a large number of personality disorders and a low number of first offenders. Comparative analyses showed substantial differences between the high and medium security settings, with a marked proportion of the forensic patients in high security having committed a sexual offence. Contrary to expectations, more predictors for length of stay were found in the medium security subsample, while admission periods were significantly longer in the high security subsample.

Ward Climate in a High-Secure Forensic Psychiatric Setting: Comparing Two Instruments

The psychometric properties and associations between the Essen Climate Evaluation Schema (EssenCES) and the Group Climate Instrument-revised (GCI-r) were examined. These self-report questionnaires assessing ward climate were filled out by 123 male patients, residing in 3 high-secure forensic psychiatric facilities. Good internal consistency was found for all subscales of both instruments. The original factor structure was confirmed for the EssenCES, but not for the GCI-r. Bivariate correlation analyses indicated that the instruments measure related concepts. The results of this study call for further development and validation and for finding common grounds in the definition and operationalization of ward climate.

Characteristics and Pathways of Long-Stay Patients in High and Medium Secure Settings in England; A Secondary Publication From a Large Mixed-Methods Study.

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood.Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England.Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings.Results: 22% of patients in high security and 18% in medium security met the definition for “long-stay,” with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample.Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

Predictive validity of the dynamic risk assessment and management system in individuals with intellectual disability residing in the community

ABSTRACTBackground. The Dynamic Risk Assessment and Management System (DRAMS) was created to measure dynamic risk in individuals with intellectual disabilities (ID). Steptoe, Lindsay, Murphy, and Young, (2008) examined the construct validity, reliability and predictive validity of the dynamic risk assessment and management system (DRAMS) in offenders with intellectual disability and found that the total DRAMS score and sections on mood, antisocial behaviour and intolerance/agreeableness predicted incidents with a medium effect size for offenders with ID residing in high secure settings.

PresentationsWorking with the impact of trauma and adversity on personal distress and offending in a high secure setting: towards a high secure model of trauma informed careUnderstanding punitive attitudes and judgements about sexual offenders Craig Harper SymposiumFuture directions in the treatment of sexual fantasiesApproaches to understanding stalking Convenor: Dr Simon Duff, University of NottinghamExploring the process of psychological risk assessment

PresentationsWorking with the impact of trauma and adversity on personal distress and offending in a high secure setting: towards a high secure model of trauma informed careUnderstanding punitive attitudes and judgements about sexual offenders Craig Harper SymposiumFuture directions in the treatment of sexual fantasiesApproaches to understanding stalking Convenor: Dr Simon Duff, University of NottinghamExploring the process of psychological risk assessment

Exploring service users’ experience of community meetings in a high secure service

Purpose The purpose of this paper is to explore service users’ experience of community meetings (CMs) within a high secure setting. Design/methodology/approach A qualitative design was employed in which focus groups were used to capture service users’ experience of CMs. In all, 12 focus groups comprising a total of 27 participants were carried out using a semi-structured interview schedule. Data were analysed using thematic and saliency analysis, identifying themes which were pertinent to the research aims. Findings Positive experiences reported by service users included a safe space to explore ward issues and develop skills, with some viewing the meeting as a therapeutic forum in which to facilitate personal growth. Research limitations/implications There were a wide range of patient presentations and views. Furthermore, only 20 per cent of the patient population were included within this study. Practical implications A number of recommendations have been identified that can have positive implications for patients (quality of life and recovery), staff (resolving conflicts and problem-solving) and the overall therapeutic milieu of the ward. Originality/value There are no reviews looking at CMs within the last decade. This paper brings the understanding up to date to allow the development of this potentially positive tool.

Mentalisation-based therapy (MBT) in a high-secure hospital setting: expert by experience feedback on participation

Evidence for mentalisation-based therapy (MBT) is increasing in relation to the treatment of personality disorder. Individuals with personality disorder are over-represented in inpatient, forensic and forensic inpatient mental health services. This study explores MBT within a forensic setting as an intervention designed to moderate deficits linked to violence and to improve adaptive coping. Interpretative phenomenological analysis was conducted on interviews with four patients who completed MBT at a high-secure hospital. Findings suggest that MBT-enhanced participants’ mentalising which had a positive impact upon their capacity to manage their behaviour and emotions. MBT further enabled participants to process past experiences of violence and develop some degree of empathy for others, which led to a trend in abstinence from risk behaviours. Findings contribute a secure inpatient perspective on the experience of MBT and to MBT clinical outcomes.

The World within the Walls: A Music Therapy Group for Patients in Long-Term Segregation at the National High Secure Service for Women in the UK

This article describes work undertaken at a high secure service for women in the UK. It provides an account of an on-ward, time-limited music therapy group for individuals detained in long-term segregation in the intensive care unit of the hospital. The high level of risk patients pose to themselves and others means mixing with their peers requires close supervision, and also results in long periods of isolation. The group was initiated with the primary focus being to help develop relationships between the women. Often the whole ward team participated, with staff members taking the role of participant-observer during the session. A background to the work, including the nature of the forensic setting, is provided. Group music therapy in this setting is then described, with consideration given to the impact of institutional dynamics on the process. The relationship between the culture of the NHS and the high-secure setting, with the inevitable struggle to maintain authentic therapeutic relationships, is also explored.