High Security Psychiatric Care Research Articles

Self-reported executive dysfunction among individuals deemed a ‘grave and immediate’ risk of harm to others: Are head injuries important?

ABSTRACT The neuropsychological assessment of individuals with a mental disorder and deemed to be a ‘grave and immediate’ risk of harm to others admitted to one UK high-secure psychiatric care (HSPC) hospital makes an important contribution to the formulation of their difficulties and treatment needs. Included within the assessments is the DEX S questionnaire, assessing the subjective experience of any executive dysfunction (ED). An examination of 205 DEX S profiles suggests ED is common, particularly among younger individuals and with no difference between those who self-report a history of head injuries. Whilst a non-clinical non-forensic classification system suggested 43.9% of individuals fall into a ‘high deficit’ category and 24.4% fall into a ‘moderate deficit’ category, a HSPC classification system suggests higher thresholds, with 22.4% and 33.2% falling in ‘high deficit’ and ‘moderate deficit’ categories, respectively. Frequently endorsed items are associated with difficulties understanding others unless things are kept simple and straightforward, acting without thinking, expressing emotions, feeling restless, and problems sitting still for any length of time and being easily distracted. Results are discussed in terms of increasing awareness of ED among those involved in the care of mentally disordered offenders, cognitive remediation and the potential for a forensic psychiatric version of the DEX.

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.

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.

Autism: Implications for high secure psychiatric care and move towards best practice

Background/aimsTo explore the role of high secure psychiatric care (HSPC) in the assessment and management of individuals with an Autism Spectrum Disorder (ASD) using published studies and clinical experience. Key areas of exploration include the prevalence of ASD within HSPC, some autism specific issues including clinical and cognitive characteristics, psychopathy and emotional regulation, presence of incompatibilities and use of seclusion, as well as experiences of being detained in HSPC. Developing best practice and a specialist ASD service in HSPC is also discussed. MethodA discussion of available literature, supported by clinical experience. ConclusionsAlthough individuals with an ASD admitted to HSPC comprise a small group, they are likely to be overrepresented relative to the general prevalence of ASD in the population and present with specific issues. Whilst individuals report a generally positive experience of HSPC, therapeutic outcomes are variable and the factors influencing them poorly understood. Staff knowledge and application of ASD theory and practice appears to have a significant influence on outcomes. Implications: Although best practice concerning ASD secure services will continue to be improved and developed, the role of HSPC in the assessment and management of some individuals with an ASD who present with complex needs and high risk behaviours remains clear.

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.

Incompatibilities and seclusion of patients with an autism spectrum disorder detained in high-secure psychiatric care

Purpose Whilst individuals with an autism spectrum disorder (ASD) represent a relatively small proportion of patients detained in high-secure psychiatric care (HSPC), previous research suggests that such individuals present with difficulties and needs significantly different from non-ASD patient groups. However, to date, there has not been any formal examination of how individuals with an ASD are represented in records of key risk management actions (i.e. seclusions and incompatibilities with other patients). The paper aims to discuss these issues. Design/methodology/approach An observation of hospital data examining two key risk management actions for a group of individuals with an ASD is detained in one HSPC hospital. These include the number of formal incompatibilities with other patients and the number of, and hours in, seclusion. Both actions require extra staff and security provisions and can decelerate the rehabilitation and recovery process. Findings In addition to suggesting an overall increase in the general prevalence of ASD within the hospital compared to previous estimates, individuals with an ASD appear to have a disproportionately higher number of incompatibilities with other patients compared to those patients without an ASD and experience more and longer periods of seclusions. Originality/value Although the methodological limitations of the study are acknowledged, explanations for the findings are discussed along with future research and recommendations as to how ASD patients might be best managed in the hospital. It is argued that the findings add further support for a specialist ASD service within HSPC.

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.

Examining the experiences and quality of life of patients with an autism spectrum disorder detained in high secure psychiatric care

PurposeAlthough individuals with an autism spectrum disorder (ASD) represent a small proportion of forensic psychiatric patients as a group they present with specific difficulties and needs. There is also evidence that if detained individuals with an ASD experience particular difficulties within custodial environments as a result of a mismatch between the difficulties associated with their ASD and the environmental demands. The purpose of this paper is to explore the experience of individuals with an ASD admitted to a high secure psychiatric care (HSPC) hospital.Design/methodology/approachUsing both a semi-structured interview and a quality of life self-report measure (the Lancashire Quality of Life Profile) the experiences and views of seven patients with an ASD detained in one HSPC hospital were qualitatively explored.FindingsWhilst a diverse range of negative and positive aspects of being within HSPC were identified by patients interviewed, those with prison experience thought HSPC was a less stressful environment with more therapeutic opportunities. As a group, patients with an ASD reported a similar or significantly better quality of life in many domains (global, leisure, financial and living situation) compared to other detained forensic patient groups.Practical implicationsAlthough most patients with an ASD interviewed reported positive experiences, there are a number of practical improvements that could be made within the hospital to reduce experienced stress levels and perhaps improve therapeutic outcomes.Originality/valueWithin the context of the Department of Health's autism strategy (2010) and subsequent update think autism (2014), the survey highlights continued ASD awareness training for staff as important. In responding to the risks and needs of individuals with an ASD in HSPC there is further support for the development of an ASD specialist service.

Everything moves on: referral trends to a leavers' group in a high secure hospital and trial leave progress of group graduates.

Moving on from high secure psychiatric care can be a complex and potentially stressful experience, which may hinder progression. A leavers' group in a UK high secure hospital is offered to support patients with this transition. The aims of this study are to investigate characteristics of patients referred for the leavers' group and compare outcomes for leavers' group graduates with those for patients who never attended a leavers' group for any reason. A retrospective quasi-experimental design was applied to data extracted from various records sources - within and outside the high security hospital. About one-fifth of patients who left the hospital on trial leave during the study were referred to the leavers' group (N = 109). Referred patients were significantly more likely to have either been admitted from another high-security hospital or transferred from prison for treatment and have a diagnosis of paranoid schizophrenia. Patients not referred had a significantly higher rate of previously refusing to participate in groups. There was a tendency for rate of return from trial leave for group graduates to be lower than that of patients who did not attend the leavers' group, but this just failed to reach statistical significance (rate ratio [RR] = 1.04; CI 0.97-1.11). A leavers' group appeared to be a valued therapy option for people who had spent a long time in high secure psychiatric care, or those who continued to require hospital treatment beyond prison tariffs. There was a low return rate from trial leave, which made the evaluation of this outcome difficult. A detailed study into both the reasons for return from trial leave and successes would provide further information on ideal preparation for moving on. Copyright © 2016 John Wiley & Sons, Ltd.

View of autism spectrum conditions held by staff working within a high secure psychiatric hospital

Purpose – Individuals with an autism spectrum condition (ASC) represent a small proportion of patients detained in high-secure psychiatric care (HSPC) with specific difficulties and needs. To date there has been little exploration of how these needs are viewed by staff or if staff have unmet needs with regard to working with ASCs. The paper aims to discuss these issues. Design/methodology/approach – A questionnaire examining specific views (on vulnerability, benefits from therapy and making adjustments to practise), knowledge and training needs linked to ASC was distributed to staff who directly worked with patients. Findings – In total, 206 questionnaires were returned (approximately 60 per cent distributed). Most staff reported making adjustments in their practise and believed patients with an ASC were more vulnerable than other patient groups. Half of staff expressed the view, that whilst patients with an ASC benefited from therapies, they were unaware if an individual’s difficulties were considered in their care. Half of staff believed individuals with an ASC should be managed in a different way. Most staff reported not having adequate skills to work with ASC, a wish for more training and that such training should be mandatory. Other than psychiatrists most staff were unaware of the Autism Act (2009). The need for a specialist ASC ward within HSPC was also highlighted by several staff. Practical implications – The survey highlights differences in staff experiences of patients with an ASC and view that autism training should be mandatory. Originality/value – Whilst progress has been made with implementing the government’s Autism Strategy (2010) within HSPC, more awareness training is required in promoting staff confidence to work with this group of patients.

Appeals against detention in excessive security (outcomes of appeals against detention in conditions of excessive security in Scotland).

The Mental Health (Care and Treatment) (Scotland) Act 2003 introduced the right for patients in high-security psychiatric care to appeal against detention in conditions of excessive security. A previous study examined the first 100 patients to appeal under this provision. In this study we compare them with the next cohort of 110 patients to lodge an appeal, finding, contrary to expectations, no change in patient characteristics or the outcome of their appeals. The clinical, legal and demographic features of successful and unsuccessful appellants, who made up 38% and 27% of the 110 patients, respectively, were also compared. Those patients with the support of their responsible medical officer and those already included on a transfer list had a significantly better chance of success (p = 0.00). It was also found that a history of excessive alcohol consumption was associated with successful appeals (p = 0.002). A diagnosis of learning disability was associated with unsuccessful appeals (p = 0.018), though the sub-sample was very small. These findings are important given the forthcoming extension of this right of appeal to other levels of security.

EPA-0469 – Translating hcr-20 risk assessment into evidence based risk management.

Structured professional judgement (SPJ) approaches are becoming increasingly influential in the assessment and management of the risk of violence in psychiatric patients. The best example is the HCR-20, that is for example is now mandatory for all patients in high, medium and low secure psychiatric care in the United Kingdom. The clinical utility of these guides has however been called into question, as their ability to be translated from risk assessment to risk management remains elusive. We will present a framework model, designed for the clinical psychiatric setting that helps to turn risk assessment into evidence based risk management. The model assists meaningful clincal implementation of risk informed intevention plans that allows teams to prioritise resources and assess treatment efficiacy and risk management success. The model requires few additional resources but can also help to facilitate communication between clincal teams at times of transition, but also between clinicians and patients.

1834 – The need for specialist service for offenders with autistic spectrum disorder within high secure psychiatric care

Introduction There are 3 High Secure Psychiatric Hospitals in United Kingdom. The Autism Act passed in 2009 introduced the Adult Autism Strategy, which sets out how local services should be improved to meet the needs of adults with Autism. There are specialist services available to care for offenders with Autism in low and medium secure forensic settings but there is a lack of dedicated support in high secure settings. Objective The objective was to identify whether current care provided for such patients is appropriate. Aim The aim of the audit was to evaluate the need for specialist service for offenders with Autistic Spectrum Disorder within High Secure Psychiatric Care. Method The hospital wide secure email system was used to identify wards which had patients with ASD. A questionnaire was developed which explored the clinical practice, willingness and knowledge of the Gold standards of care. It was circulated on the 9 identified wards to the staff on 3 different shifts. 100 completed forms were received which were stored in a secure area. Results The results revealed that most of the staff was aware about ASD but majority had not heard about standard approach of care. Majority of the staff were willing to train and work in a dedicated ASD team. Conclusions Effort should be made to increase awareness and train the staff to care for offenders with ASD. Work should be done towards accreditation with the National Autistic Society to set up specialist care for ASD patients in High Secure Unit.

Autism spectrum quotient (AQ) profiles among male patients within high security psychiatric care: comparison with personality and cognitive functioning

The autism spectrum quotient (AQ) is a screening tool used to assess self-reported autistic traits. However, the available comparative data are based on non-forensic samples, with little examination of the relationship with other aspects of personality or cognitive functioning. An examination of the AQ among a high secure psychiatric sample of patients with an autistic spectrum disorder (ASD), a mental illness and a personality disorder is described. Analysis revealed that whilst the AQ can discriminate ASD patients, the social skills, communication and attention switching subscales are most sensitive. A regression analysis revealed that 45% of the variance in the AQ total score can be predicted by the Millon self-report personality measure. No significant relationships were present between the AQ, full-scale IQ, a mentalisation task and measures of executive functioning. The use of the AQ among forensic psychiatric patients is discussed along with a need for an AQ forensic version.

Extreme violence in a man with an autistic spectrum disorder: assessment and treatment within high-security psychiatric care

Autistic spectrum disorders (ASD) are lifelong neurodevelopmental disorders characterised by significant impairments in social communication, social interaction and in different dimensions of imagination such as with perspective taking. Individuals with an ASD who commit violent offences typically present as a challenge to clinicians and struggle within conventional forensic psychiatric services. A case study is described of a young man with an ASD convicted of manslaughter and admitted to high-security psychiatric care (HSPC). His detailed psychological assessment is described, along with an offence formulation and subsequent psychological interventions within HSPC. Additional issues relating to mental capacity, risk assessment and future management are highlighted. A final discussion is given towards some general issues relating to the role of HSPC in the assessment and management of individuals with an ASD who commit serious offences.

Hare Psychopathy Checklist Revised profiles of male patients with Asperger's syndrome detained in high security psychiatric care

‘Asperger's syndrome’ (AS) is a pervasive developmental disorder falling at the high end of functioning along the autistic spectrum. It is characterized by significant impairments in social communi...

Theory of mind in Asperger's syndrome, schizophrenia and personality disordered forensic patients

Introduction. The ability to conceptualise other individuals' mental states is dependent on having a ‘theory of mind’ (ToM). Individuals with Asperger's syndrome typically display ToM impairments, as do some individuals with schizophrenia, notably those with paranoid delusions. The presenting features of these and other individuals, such as those with some personality disorders, particularly in forensic patients, are often unclear. ToM performance was examined to see whether it could distinguish forensic patients with Asperger's syndrome from other patient groups. Methods. The performance of three male patient groups (N = 39) detained in high security psychiatric care, including those with Asperger's syndrome, schizophrenia (with paranoid delusions and/or auditory hallucinations as their predominant symptoms), or a dissocial and/or borderline personality disorder were compared using the revised eyes task and the modified advanced ToM test. Results. The Asperger's syndrome and schizophrenia groups performed significantly worse than the personality disorder group on both ToM measures. However, the Asperger's syndrome and the personality disorder groups had significantly higher levels of general intellectual functioning than the schizophrenia group. Conclusions. Whilst ToM performance may help to discriminate patients with Asperger's syndrome or schizophrenia from personality disorder ed patients, a wide range in performance made it difficult to specify a patient to a particular group. Theoretical and methodological issues are discussed along with the usefulness of ToM assessments with forensic patients.

The Detection and Treatment of Substance Abuse in Offenders with Major Mental Illness: An intervention study

Previous research demonstrated that alcohol and drug misuse prior to admission to special (high and medium) security psychiatric care in Scotland was high. Evidence from clinical practice subsequently suggested that the situation was worsening. In response, a three-pronged strategy was implemented: staff were trained in alcohol and drug issues in mentally disordered offenders, an admission screening programme was introduced to detect those at risk, and specific interventions were developed. This paper presents data on the admission screening programme and on a specific intervention. Study 1 describes the admission data on 86 male patients admitted to the State Hospital, Carstairs. It confirmed that alcohol (81%) and drug (75%) misuse were rising in this population. Combined drug and alcohol abuse was common resulting in the development of joint treatment interventions. Study 2 describes an eight-week drug and alcohol education and awareness programme. An evaluation of this intervention showed that subjects' knowledge of alcohol and drug issues rose significantly pre to post-intervention. However no difference was found in the stage of change or locus of control measures. A number of possible explanations for this finding are discussed, including the validity of the instruments and the effect of detainment in a high security psychiatric environment on the opportunity to change. In spite of the limitations of the environment, the prevalence of alcohol and drug misuse and its association with violence emphasise the need for specific programmes.

Detecting the dangerous, violent or criminal patient: an analysis of referrals to maximum security psychiatric care.

Britain's high security hospitals provide care for mentally disordered patients who have dangerous, violent or criminal propensities. The State Hospital, Carstairs, takes referrals from the population of Scotland and Northern Ireland. This retrospective case-control study describes the sociodemographic and clinical characteristics of referrals (n=149) to the State Hospital during a 12-month period, and delineates differences between admitted (n=57) and rejected (n=92) patients. The referrals had an average age of 31.1 years, and were mostly male (86.6%), single (64.4%) and unemployed (90.6%). Admitted patients were more likely to have a criminal history, to be psychotic, to have a family history of mental disorder and to be viewed by the assessor as having psychotic beliefs which contributed to the behaviour or alleged offence leading to the referral. Rejected patients were more likely to have been remanded to prison or assessed by specialist registrars. Patients admitted to high security psychiatric care are more likely to show dangerous behaviour secondary to psychosis. These findings are in keeping with the requirements of mental health legislation and the admissions policy.

Substance dependence and schizophrenia in patients with dangerous, violent and criminal propensities: a comparison of co-morbid and non-co-morbid patients in a high-security setting

Studies show that schizophrenia is associated with increased substance misuse/dependence. An association exists between co-morbidity and violence/offending. Our aim was to compare substance-dependent and non-substance-dependent patients with schizophrenia, by using patient interviews and retrospective case-note data. A sample of 169 patients with schizophrenia in high-security psychiatric care was divided into two groups by using the absence/presence of substance dependence. Diagnoses were made using St Louis criteria. Of the patients, 88.8% were male. Lifetime rates of substance misuse showed that 53.8% had a history of alcohol misuse and that 53.3% had a history of drug misuse. Co-morbid substance dependence was present in 41.4% and schizophrenia alone in 58.6%. Co-morbid patients were more likely to be from the west of Scotland, to have a history of convictions and to be intoxicated prior to admission. They were more likely to be treated with anti-cholinergics or anti-depressants, to suffer affective symptoms or to have anti-social personality disorder. They were less likely to have negative symptoms, thought disorder, or learning disability and less likely to be civilly detained. This study finds high rates of substance misuse/dependence occurring co-morbidly with schizophrenia in Scottish high-security settings. Co-morbidity is associated with increased offending. Differences in symptom profiles and demographics may have potential implications for recognition and risk management.