High Secure Care Research Articles

Time From Referral to Discharge From High Secure Care: Challenges for Flow Through the Forensic Estate

Time From Referral to Discharge From High Secure Care: Challenges for Flow Through the Forensic Estate

Étude nationale française du profil des patients hospitalisés en unité pour malades difficiles

The ten French psychiatry high security care units (Unité pour Malades Difficiles : UMD) are the only forensic institutions in the country to provide care for dangerous and/or difficult patients (homicide, acts of barbarity, sexual assault, cannibalism, pyromania…). They benefit from intensive care protocols and high security measures. In this first epidemiological multicentric descriptive study in French history including 418 violent and homicidal patients, medico-judiciary and social characteristics of the standard UMD patient are described. This standard patient is a young single man, with a criminal record and from an underprivileged background, suffering from treatment-resistant schizophrenia with strong delusional symptoms. He has a weak compliance to treatment, low insight, a history of drug abuse and is admitted for severe violence against others and in particular against caretakers or for homicidal act. The study's secondary goal is to revisit the risk factors of high violence described in medical literature and to reveal new ones (cultural uprooting, parental psychopathology, homelessness, perverse sadistic behavior, aggressive behavior a month prior the violent acting out, resistance to antipsychotic drugs, treatment discontinuation), particularly in the homicidal patient cohort. This study should enable clinicians to evaluate dangerousness and to offer better medical care and preventive measures against violence.

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.

Security needs among patients referred for high secure care in Broadmoor Hospital England.

Security needs among patients referred to forensic mental health services have rarely been systematically studied. To ascertain security needs among patients referred to a high secure hospital, Broadmoor High Secure Hospital, England. We also aimed to compare the security needs for those referred to mental illness services with those referred to personality disorder services in the hospital. A retrospective complete cohort study of all referrals to Broadmoor Hospital over a 2-year period was conducted. All referred patients (n = 204) were assessed for need for high secure care by two Broadmoor clinicians. The final decision on need for admission was taken by a multidisciplinary admission panel. Independent of the panel, researchers rated need for security using the DUNDRUM-1 triage security scale. Those admitted to Broadmoor Hospital had higher triage security scores than those declined (F = 4.209, d.f. = 1, P = 0.042). Referrals to the personality disorder pathway had higher security needs than those referred to the mental illness pathway high secure service (F = 6.9835, d.f. = 1, P = 0.0089). Overall security needs among referrals to Broadmoor were extremely high, both by comparison with previous needs identified in UK medium secure services and international medium and high secure services. High secure patient cohorts represent a uniquely vulnerable group within mental health services, with extremely high security needs identified in this study. This has significant implications for services given the high levels of resources needed to provide therapeutically safe and secure care and treatment to this group.

The experience of long stay in high and medium secure psychiatric hospitals in England: qualitative study of the patient perspective

BackgroundSome forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues. Research focused on the patients in secure care has examined quality of life and service provision but not the perspectives of patients experiencing long stays. This study explored how long stay patients experience secure care, what factors they felt influenced long stay, and its impact upon treatment engagement and motivation to progress.MethodsEmbedded within a larger epidemiological study, we conducted semi-structured interviews with a purposive sample of forty long stay patients from two high and six medium secure hospitals. Long stay was defined as a 5 years stay in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure. Transcripts were subject to thematic analysis, and narrative analysis at individual case level to explore the relationship between emergent themes.ResultsFour themes emerged illustrating participants’ attribution, outlook, approach, and readiness for change. A typology of four long stay stances was developed (dynamic acceptance, dynamic resistance, static acceptance, static resistance). These illustrate differences in the extent to which participants believed being in secure care helped them to get better, and actively work towards progression and leaving secure care. There were considerable differences in how patients adopting these stances attributed the reasons for their long stay, they viewed their future, and their motivation to progress. Negative perceptions arose from excessive restrictions, treatment repetition and changes in therapeutic relationships, leading some patients to exhibiting tokenistic engagement and low motivation to progress.ConclusionsPlanning care for long stay patients in secure psychiatric settings should take account of the differing stances patient’s adopt towards engagement and progression. Service providers should be mindful of these stances and provide patients with individualised opportunities to progress through the secure care treatment pathway, avoiding treatment repetition and maintaining continuity in key professional relationships. Refocusing on quality of life may be appropriate for some long-term patients who are unwilling or unable to move on. For some long-term patients, purpose designed long stay setting may be appropriate.

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.

A protocol in action: Recovery approach for patients within high secure care: A 20+year follow-up.

ObjectivesA person‐centred approach to recovery is increasingly represented within mainstream mental health literature. Little examination of recovery among forensic mental health patients is evidenced. This study plans to address that insufficiency.MethodsThis protocol paper details a novel approach to exploring recovery among a cohort of 241 patients detained under conditions of high secure care in Scotland during August 1992 to August 1993. Under discussion is the repurposing of previous research to circumnavigate length of inpatient stay commonly associated with forensic mental health care. The methodology adopted, while considering data leakage given the vulnerable participant group, will be discussed.ResultsRepurposing and extending previous research attempts to address the file cabinet effect with 85% of health care research being wasted and future uncertainty regarding research funding in a post‐Brexit era. This is an ongoing study. Ethical, confidentiality, privacy issues, and permissions are considered within the methodology.ConclusionsEthical arguments can be made for tracing and attempting contact with vulnerable groups under‐represented in the literature. A well‐considered methodology putting the focus on participant welfare and confidentiality at every step is essential. The reported methodology provides an opportunity to expand and re‐examine previously collected data through a contemporary lens.

English vs Dutch high secure hospitals: service user perspectives

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

Long-stay in high and medium secure forensic psychiatric care – Prevalence, patient characteristics and pathways in England

IntroductionForensic psychiatric services are costly and highly restrictive for patients. Clinical experience and the limited research available indicate some patients stay for too long in these settings. A proportion of patients may, however, require long-term (potentially life-long) secure forensic psychiatric care but their needs may not be met by existing service provision designed for faster throughput.ObjectivesWe conducted a national, multi-centre, cross sectional study exploring the prevalence of long-stay and characteristics of long-stayers in high and medium secure forensic psychiatric care in England.Aims(1) Estimate the prevalence of long-stay in secure settings in England (length of stay over 5 years in medium secure care or 10 years in high secure care); (2) describe the characteristics, needs and care pathways of long-stay patients. Develop recommendations following the exploration of international models for this patient group.MethodsWe employed a mixed-methods approach including the analysis of administrative data, case file reviews, patient interviews, consultant questionnaires, interviews with clinicians and commissioners and a Delphi survey.ResultsTwenty-five percent (n = 401) of our sample were experiencing long-stay. This patient group has a heterogeneous set of characteristics and needs relating to their diagnosis, offending history, risk and therapeutic need and have experienced a variety of care pathways through secure care.ConclusionsWe found a greater number of long-stay patients than originally estimated with a set of characteristics and needs that are arguably different to that of the general forensic population, therefore calling for a specific care pathway and service provision for this patient group with a greater focus on autonomy and quality of life.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The development of recovery based nursing in a high-security hospital: nurturance and safe spaces in a dangerous world?

Purpose – The purpose of this paper is to derive from an on-going, innovative, project to explore the concept, and application, of “recovery” in the care and clinical management of patients detained in one UK high-security hospital. Design/methodology/approach – Utilising a qualitative, action research, methodology the aim was to involve forensic mental health nurses in a collaborative, client-centred approach to identification and resolution of dilemmas in the process of planning care for offender-patients. Findings – In this context the authors identify constraints and contradictions involved in employing recovery principles in institutions critics refer to as part of the disciplinary apparatus of psychiatric and social control; where the taken for granted lives, and relations, of an incarcerated population are measured by the calendar, not the clock. Research limitations/implications – Protective practices remain highly relevant in high-secure practice. Safety, an important value for all can by and large be achieved through recovery approaches. The humanistic elements of recovery can offer up safe and useful methods of deploying the mental health nurse on the ward. Many nurses have the prerequisite approach but there remains a wide scope to enhance those skills. Many see the approach as axiomatic though nurse education often prepares nurses with a biomedical view of the ward. Practical implications – Currently, philosophical tenets of recovery are enshrined in contemporary health policy and professional directives but, as yet, have not been translated into high-secure settings. Drawing on preliminary findings, attention is given to the value of socially situated approaches in challenging historic dominance of a medical model. Social implications – It is concluded that recovery could be a forerunner of reforms necessary for the continued relevance of high-secure care into the twenty-first century. Originality/value – This research is located in high-secure setting. The social situation is marked by the extent of the isolation involved. A value is in this situation. First it is akin to the isolation of the tribe utilised by many anthropologists for their ability to adopt the “social laboratory” status to test out theories of behaviour in industrial society. The authors urge others to utilise this research in this way. Second, the situation represents the locus of so many of societies dilemmas, paradoxes and fears that moral issues morph from what is the mundane in wider society. In this way humanistic approaches are tested via action research with nurses in some rigouous ways.

Recovery, turning points and forensics: views from the ward in an English high secure facility

Purpose– The authors offer up an example of recovery in a high-secure setting. The purpose of this paper is to highlight how an individual account of recovery and the academic literature offer up related and important perspectives that have serious clinical utility.Design/methodology/approach– First the context is outlined. The biographical account is then deployed to describe the experience of being detained in an English high-secure facility using recovery as a framework for elucidation. This is often referred to in recovery as accessing the views of the “expert by experience”. In a thematic way this author details his understanding of recovery, what worked and what did not. This account is then contrasted with the academic literature and research at the same site. Social anthropology acts as the theoretical backdrop. This debate informs some clinical implications and issues for practice.Findings– Recovery can be a highly relevant concept in a high-secure context. The author found that the biographical account of the “patient” can offer the observer some insights for practice. The authors noted that the collective themes of previous research where consistent to this account. The authors found the use of recovery principles helped the person receiving care fulfil his potential. Nevertheless, forensic recovery implies a forensic past. This complicates recovery and placed limits on the own use of the principles.Social implications– The authors argue that recovery is highly relevant to the context and particularly important to people who are often stigmatized for multiple reasons including their, “illness”, their “crime”, and their social situation. The paper implies that forensic recovery is more problematic than mainstream recovery. Key events mark out issues.Originality/value– This is the first co-produced paper surrounding recovery in high-secure care.

EPA-0119 – Characteristics and needs of long stay patients in high and medium secure forensic psychiatric care - implications for service organisation

Introduction Forensic-psychiatric services are costly and very restrictive for patients. Clinical experience and the limited research available indicate that some patients stay for too long in these settings. A proportion of patients may, however, require long-term, potentially life-long, secure forensic-psychiatric care but their needs may not be met by existing service provision designed for faster throughput. Here we report the initial findings of a three year study on long-stay patients in forensic care conducted in England. Objectives The overall objective of this project is to improve the quality and cost-efficiency of the care and management of patients who stay for prolonged periods in secure forensic-psychiatric settings. Aims 1. Estimate the number of long-stay patients in secure settings in England (length of stay over 5 years in medium secure care or 10 years in high secure care) 2. Describe their characteristics, needs, care pathways and reasons for prolonged stay 3. Identify patients’ perceptions of their treatment pathways, long-term needs, service provisions and quality of life 4. Develop recommendations following the exploration of international models for this patient group Methods This project uses a mixed-methods approach including analysis of administrative data, case file reviews, patient interviews, interviews with clinicians and commissioners and a Delphi survey. Results Initial findings indicate that up to 25% of the forensic population fulfill criteria for long-stay, a much greater number than originally estimated. Conclusions The high number of long-stay patients in high and medium secure services calls for specific service provision for this patient group, which we will explore further.

An evaluation of the staff training within the trauma and self injury (TASI) programme in the National High Secure Healthcare Service for Women (NHSHSW)

PurposePatients in the National High Secure Healthcare Service for Women have a high prevalence of trauma and self injury. This highlights the need for specialised training of staff dealing with such women. The aim of this study was to evaluate the trauma and self injury (TASI) training programme on staff knowledge and skills.Design/methodology/approachA total of 135 nurses and nursing assistants participated in the TASI two‐day training course. Questionnaires allowing for quantitative and qualitative data collection were completed before and after the training. Training and confidence levels in dealing with women who self‐harm prior to the training were identified and the impact of the programme was assessed.FindingsThe majority of staff had not received any previous training on trauma and self injury. There was an increased level of confidence in working with trauma and self injury following training and staff reported an increased ability to ask for support. Self‐perceived competence improved to a greater extent in those who had not received previous training compared to those who had.Research limitations/implicationsThe authors' data is limited to self‐report. Future research should use objective measures to evaluate the impact of staff training.Practical implicationsA relatively short training programme focusing on trauma and self injury appears to improve staff confidence, understanding and competence in working with women patients in a high secure setting. Similar training programmes might also be beneficial in different patient groups with complex backgrounds and behaviours.Originality/valueThis is the first report on a training programme focussing on women in high secure care who self‐harm and have experienced trauma.

Les auteurs de violences sexuelles en unité pour malades difficiles

IntroductionLiterature concerned with the care of the mental patients perpetrators of sexual violence in psychiatric high security care unit is sparse and fragmented. According to studies, it is reported that a small proportion of such patients that suffer are between 3 and 5%. These patients are described as perverse and incurable and no subject to any treatment with the exception of surveillance in institutional settings. Based on the observation of an ancient literature and limited, our aim was to realize a study covering the year 2010. This proportion, has it changed? What are the profiles of sexual offenders in this care unit? Material and methodWe realized a retrospective study with all patients who were hospitalized in care unit for dangerous patients covering the year 2010 in Sarreguemines. We studied a sample of 124 patients who were all in forced hospitalization. We identified forensic history, judicial history, and sexual violence history for every patients who were studied. ResultsSexual violence concerns only 10% of transfers in care unit for dangerous patients over the period studied. In this case, it's mainly sexual assaults occurring in community settings and not psychiatric. Sexual violence constitutes an indication of the forced hospitalization then transfer in this care unit. However, we find history of sexual violence in nearly 30% of patients being hospitalized in the care unit. It's primarily mental retardation closely followed by schizophrenia. These patients with history of sexual violence have important comorbidities: consumption of toxic and personality disorder. Finally, the prevalence of paraphilias remains low and only concerns 16% of sexual offenders in psychiatric high security care unit. DiscussionIt was admitted in literature that patients perpetrators of sexual violence were infrequent in dangerous patient care unit especially sexual perverts. Against all odds, one third of patients hospitalized in this care unit have committed sexual assault (a large proportion). More than half of these patients with mental retardation, schizoaffective disorder, bipolar disorder or personality disorder. Only 13% of schizophrenic patients have committed sexual violence: it's a small proportion compared to other mental illnesses. ConclusionThe profile of sexual pervert exists in psychiatric high security care unit (sexual homicide with torture and barbaric act) but it's an uncommon cases. Sexual violence is frequent among hospitalized patient in psychiatric high security care unit (sexual violence found are varied: sexual touching, attempted rape of a nurse).

A review of the factors that influence high, medium and low secure care pathways

The forensic care pathway that is the focus of this UK regional review has itself seen a considerable amount of change over the last decade, focusing on implementing wide reaching reform within both prison and health care. Reforms have seen a reduction in the number of people in some parts of the care pathway and new interventions and growth in other areas. At the end of 2009, the region that was subject to this review there had seen over 450 people cared for in high, medium or low secure services in that year and had a prison population approaching 10,000. The aim of the review was to understand the impact of these changes with a view to sustaining effective pathways and systems, and to increase impact and ensure value for money in order to improve the efficiency and quality of services. A primary objective was to consider the influence of statutory mental health provision upon the use of high, medium and low secure psychiatric services. It was proposed that from a regional perspective more needed to be understood about the influence of wider services upon the care pathways for people using secure services. This paper considers what is available from primary care locality and its features, alongside the rates of secure service use. It also acknowledges the wider influences upon the use of those services.

Women Admitted to Medium Secure Care: Their Admission Characteristics and Outcome as Compared with Men

Background: Whilst women admitted to secure care are believed to require gender-specific services, there is limited research to inform their provision. Method: Clinical and forensic characteristics and outcomes on 93 women were obtained from multiple data sources and compared with 502 men admitted to the same medium secure unit over a 20-year period. Results: Compared to the men, the women were more likely to have more mental health needs and less criminality. At discharge, women were more likely to be transferred to secure care and less likely to be transferred to prison. Following discharge, the women had a higher rate of mortality. While reconviction rates were similar for the two groups for serious offenses, violent or arson incidents not leading to conviction were more likely for women. The women were more likely to be readmitted, and to be readmitted to high secure care. Conclusion: Despite more favorable criminological characteristics at baseline, our data suggest a poorer outcome for women overall following discharge.

Waiting times at a high-security hospital – a survey of the process from referral to admission at Ashworth Hospital

Long waiting times are a major concern in many NHS settings and this is also the case in forensic services. Forensic psychiatric admissions tend to be lengthy, and progress through the system is slow. Yet, little research has been conducted exploring waiting times for admission to high-security care and factors contributing to delays in such admissions. Here we describe the progress of referrals to Ashworth Hospital over a two-year period, 2005 and 2006. Medical reports took an average of 41.3 days from referral. The average waiting time from referral to admission was 127.4 days, but 60% of cases were admitted within 22 weeks. Factors associated with delays in the process from referral to admission included diagnosis and place of referral. Those with personality disorders and those referred from prison encountered particular delays. Lateness of assessment reports had a knock-on effect on subsequent progression. Bed capacity had no significant effect on waiting times for admission.

Defining high, medium, and low security in forensic mental healthcare: the development of the Matrix of Security in Scotland

As differing levels of security in forensic mental healthcare have evolved, there has been no clear or concise agreed definition of high, medium, or low secure care. This paper reviews the historical use and abuse of security as treatment. More recent attempts to define security level and purpose are reviewed, and the trinitarian model of relational procedural and physical security is described. In Scotland there has been a need to define security levels for the purpose of private sector registration, service development, and, most particularly, appeals against excessive security made under new mental health law. The Matrix of Security which has been developed in Scotland, and those aspects of physical and procedural security that differ between security settings, are described.

Beauty in the eye of the beholder? How high security hospital psychopathically-disordered patients rate their own interpersonal behaviour

As service user involvement, particularly through ‘expert patient’ schemes, increases for service development and implementation in the UK, we investigated the concordance between how patients with personality disorder view their interpersonal functioning and the views of staff who care for them in a high security mental health setting. We compared self and observer ratings of interpersonal functioning for 55 legally-defined psychopathic disorder patients detained in a high security psychiatric hospital using the CIRCLE, an instrument designed to assess interpersonal functioning. We found that male patients underestimated their worst qualities, such as dominance (p < .0005) or coerciveness (p < .0005), and overestimated their best qualities, such as nurturance (p < .0005), a finding not intuitively surprising but which confirms aspects of previous research. This result raises the questions of how such discordance should be interpreted, whether self or observer ratings should be considered more valid, and whether such findings have a bearing on both future risk assessment and the individual's eventual movement from high secure care.

The needs of males detained under the legal category of ‘psychopathic disorder’ in high security: Implications for policy and service development

Approximately a quarter of the high secure psychiatric hospital (HSPH) population is detained under the 1983 Mental Health Act legal category of ‘psychopathic disorder’ (PD). To date, there have been no studies specifically examining the security, treatment, and placement needs of this group despite recent policy developments. We conducted a cross-sectional survey of the needs of all males detained under the legal category of PD in the HSPHs in England. We found that 60% continued to require high secure care. Ongoing needs primarily related to substance misuse, interpersonal relationships, and sexual offending. Security and political issues were key factors associated with the continued need for HSPH care. High levels of Axis I and II co-morbidity were found. Although a substantial proportion did not require HSPH care, organisational and service-related factors prevented or delayed their transfer to appropriate services. The findings are discussed in light of proposed legislative reforms and service developments.