High Secure Psychiatric Hospital Research Articles

The Life Sentence: Using a Narrative Approach in Group Psychotherapy with Offenders

In this article, I will discuss a narrative approach to psychodynamic group work with offenders. Drawing on my experience of running groups for offenders in a high secure psychiatric hospital, I will argue that (a) identity is created in narratives and stories and (b) that psychodynamic therapies allow people to change their narratives of themselves; and (c) that this is particularly significant when the story that must be told is one that involves a violent crime. I will try and set out how offender patients come with ‘cover’ stories, which are thin, and incoherent, and explore how dialogue in groups can facilitate changes of narrative and thus transform a thin story into something richer and more self-reflective.

Dangerous Severe Personality Disordered (DSPD) Patients: Characteristics and Comparison with Other High-Risk Offenders

England and Wales introduced the administrative category of Dangerous Severe Personality Disorder (DSPD) and established special units in prisons and high-secure psychiatric hospitals for their treatment. To examine their characteristics, we approached 202 patients admitted to DSPD units; 174 consented to participate in research. All were male, and the median age was 38 years. Most were white and born in the UK. Most patients (75%) met full DSPD criteria as suffering from severe personality disorder that caused them to be dangerous. With respect to personality disorder, most had elevated psychopathic traits and 40% met criteria for psychopathy on the Psychopathy Checklist-Revised (Hare, 2003). With respect to dangerousness, 25% of patients had a history of homicide; 28%, sexual offenses; and 41%, other violent offenses. Median time spent in prison was more than 12 years. According to standardized measures of violence risk, those admitted to DSPD units resembled other groups of high risk offenders described in the international literature. There were some significant differences between those admitted to prison- versus hospital-based units. The findings confirmed that DSPD units contain dangerous offenders with no evidence of preemptive incarceration.

Jimmy Noak

Broadmoor Hospital is arguably the most renowned of England's three high-security psychiatric hospitals. Deputy Director of Nursing Jimmy Noak shares his experience with BJW

Predictive Validity and Other Psychometric Properties of the Short-Term Assessment of Risk and Treatability (START) in a Norwegian High Secure Hospital

Short- to medium-term risk assessment in psychiatric hospitals is a topic of clinical relevance that deserves attention from the research community. In this paper, the Short Term Assessment of Risk and Treatability, or START (Webster, Martin, Brink, Nicholls, & Middleton, 2004), a new structured instrument for judgment of dynamic risk and treatment factors is briefly described. Internal reliability properties are analyzed and the predictive validity for severe violence in a Norwegian high secure psychiatric hospital is investigated. The results indicate that the START has promise as a valid tool for short-term violence risk assessment. The authors make an argument for the importance and relevance of dynamic risk and strength factors in the short to medium term.

Impact of a total smoking ban in a high secure hospital

Aims and methodTo assess the impact of a total smoking ban in a high secure psychiatric hospital. Staff and patients were surveyed before and after implementation. Data were collected on untoward incidents, seclusions, nicotine replacement therapy and changes in psychotropic medication.ResultsOf the 298 patients in the hospital for the evaluation period, 72.8% were smokers before the ban. There were no significant differences in rates of seclusion before and after the ban and only one significant comparison (P =0.01) showed an increase in untoward incidents for smokers. There were no significant increases in the use of psychotropic medication after the ban.Clinical implicationsWith adequate preparation, it is possible to implement a total smoking ban in a high secure psychiatric setting without serious negative consequences.

The assessment of imminent inpatient aggression: a validation study of the DASA-IV in Scotland

Inpatient aggression in psychiatric settings poses a serious management problem. This study reports the findings of a prospective pilot study on the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA-IV), a structured risk assessment tool for imminent aggression. The study was conducted in the State Hospital, the high secure psychiatric hospital for Scotland and Northern Ireland. The outcome data were aggressive incidents recorded on the Staff Observation Aggression Scale – Revised (SOAS-R) and incidents noted on the hospital's online recording tool. All measures were completed by nursing staff as part of their daily clinical routine to ensure ecological validity. The DASA-IV was found to be of moderate to good predictive power. Limitations and suggestions for further research are outlined, and the potential for implementation of the tool is discussed.

Difficulties in the pathway from high to medium secure services for personality-disordered patients

Personality-disordered patients detained in high secure psychiatric hospitals appear to experience difficulties progressing to medium secure services. Accordingly, this study sought to explore the problems encountered in this pathway. To do this, data relating to referrals to medium secure services were collated for previous and current patients from a Personality Disorder service (n = 68) and a Dangerous and Severe Personality Disorder service (n = 12) in one English high secure hospital. The results highlighted the poor success rate of referrals to medium secure units and revealed the extensive delays encountered in the transfer process. Further to this, they also identified the poor success rate of patients periods of trial leave at medium secure units. Taken together, these findings are consistent with reports that consultants in medium secure units are reluctant to accept personality-disordered patients and that these units lack the infrastructure to treat this patient group.

Audit of hand hygiene at Broadmoor, a high secure psychiatric hospital

Increased security measures at high secure psychiatric hospitals can complicate hand hygiene. This audit assessed the availability of appropriate hand hygiene equipment and the practice of good hand hygiene at Broadmoor Hospital using the local hand hygiene policy as the standard for comparison. A data collection tool used to audit the hand hygiene equipment on 23 wards in the hospital showed that there were significant deficits in the supply of hand hygiene equipment on the wards. In addition, a staff survey was conducted using a questionnaire designed to assess awareness, training and hand decontamination practice among nursing staff. This survey identified a need to increase awareness of the hand hygiene policy and the appropriate timing of hand decontamination procedures. As a result of the audit, appropriate equipment was ordered and the duties of infection prevention link nurses on each ward were made more explicit; namely, to check and order equipment for hand hygiene as necessary, to conduct regular reminder sessions of the hand decontamination procedure and to raise awareness of hand hygiene policy. Posters were also placed on wards in patient areas to increase awareness of hand hygiene among patients, and alcohol gel dispensers were introduced into nursing stations. Similar audits may prove beneficial at other psychiatric hospitals.

Outcome of high security patients admitted to a medium secure unit: the Edenfield Centre study

This study examined the outcome of a cohort of 72 patients from a high secure psychiatric hospital (HSPH) who were admitted to and discharged from the Edenfield Centre over a 16-year period. The sample was predominately male and mentally ill and the majority was subject to restriction orders. Compared with two similar studies focusing specifically on the outcomes of HSPH patients in medium security, our sample had fewer women and the group had more extensive criminal and psychiatric histories. None of our cohort was discharged to the community via district services or transferred to other hospitals. We found that the Edenfield Centre had relatively higher rates of readmissions to the HSPH and a slightly higher reconviction rate than similar studies focusing solely on the outcomes of HSPH patients. In line with previous research, those detained under the legal category of psychopathic disorder were more likely to be reconvicted following discharge to the community than those detained under mental illness. Further large scale studies are needed to compare the outcomes of HSPH patients discharged through medium secure services that operate parallel or integrated aftercare service models.

Recorded incidents in a high‐secure hospital: A descriptive analysis

Incidents of violence, self-harm and security are of concern in psychiatric hospitals with regard to both patient and staff welfare. The purpose of this study was to examine the frequency and nature of incidents in all directorates in a high-security psychiatric hospital. Data were collected from the hospital's incident recording forms for the period 1 June 2007 to 30 September 2008. In total, 5658 incidents were recorded, almost all patients (95%) having been involved in at least one incident. Most incidents, however, were in the categories of less serious violence and self-harm. The rate was 0.89 incidents per patient per month. The women's directorate had a significantly higher frequency of violent or self-harm incidents than the other directorates (male mental health, learning disability, personality disorder or dangerous and severe personality disorder). Violence was almost equally against fellow patients or staff. It was commonest in communal areas during day-time hours. Self-harm was most likely in a patient's own room. These findings can inform prevention and management of violence and self-harm. Dealing with such a large number of incidents is time consuming, even if they are not especially serious. Attention to environmental, as well as individual, issues is recommended.

Patient‐to‐patient bullying in secure psychiatric services: exploring the value of official records for documenting patient‐to‐patient bullying

The study presented here examines the reporting of patient‐to‐patient bullying in a high secure psychiatric hospital housing adult men. It examines official records of bullying recorded on Suspected Bullying Report forms (SBRs), noting motivations for bullying and exploring how information was recorded. Its subsidiary aim was to explore the value of official records, presenting comparison data from three patient bullying surveys completed at the same hospital. All suspected reports of bullying in the hospital documented for a two‐year period were collected. The patient surveys included data from three data‐sets collected at the same hospital over a five‐year period. The prediction that the patient surveys would suggest a higher level of bullying behaviours than official records was confirmed. Results for official records also demonstrated that motivation for bullying was either not recorded or was reported as a typology, bullying was not likely to be recorded as hospital incidents, and perpetrators were unlikely to be offered supportive intervention. The results are discussed with regard to the value of official records as a reporting mechanism.

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

Nurses’ attitudes towards sexual relationships between patients in high security psychiatric hospitals in England: An exploratory qualitative study

Background The issue of relationships between patients in long-term care settings can present nurses with numerous challenges. However, addressing this element of patient care is recognised as an important element of nursing in this sphere of practice. What nurses think about patient sexual relationships and the difficulties of incorporating these into care is closely linked to the care they provide. However, the issue of patients sexual relationships within high security psychiatric hospitals is a relatively poorly researched area of clinical practice. Aim To explore the attitudes towards patients’ sexual relationships held by nurses working in high security psychiatric hospitals in England. Methods and participants A qualitative methodology was employed with data collected from 10 in-depth interviews with nurses working within secure psychiatric hospitals in England. Interview data were subjected to thematic analysis. Results Practitioners reject permissive policy in relation to patients’ sexual relationships on account of perceived perpetuation of abuse and exploitation. Practices and attitudes are dominated by personal (lay) values that seek to restrict patient experience and undermine professional mores whilst also seeming to uphold a professional duty of care. Conclusion Lay understandings are constructed as moral rights and priorities that are of higher order concern than professional values or the rights of the individual. This constitutes a clash of values and the minimisation of professional mores within the clinical context raises questions about the role of professional teaching, knowledge and policy in relation to professional socialisation.

Is sexually abusive behaviour in personality disordered inpatients analogous to sexual offences committed prior to hospitalization?

Sexually abusive behaviour by personality disordered patients presents a serious threat to the integrity of staff–patient relationships and the safety of other residents. The occurrence of such behaviour is also problematic for the offending patient, as it may impact on perceived treatment needs and their access to the community. This paper reports on a study of sexually abusive behaviour in a high security psychiatric hospital. It also examines the relationship between these behaviours and patients’ history of sexual offending. The results showed a high frequency of low-severity sexually abusive behaviour and no significant associations between sexually abusive behaviour during hospitalization and sexual offence history. These findings imply that low-severity sexually abusive behaviour within secure settings may be determined, partly, by environmental conditions. This sexual abuse may also be functionally dissimilar to severe sexual abuse perpetrated in the community. The meaning and determinants of sexual abuse within secure settings must be scrutinized carefully and comprehensively before they are considered analogous to previous sexual offences.

OPRISK: A structured checklist assessing security needs for mentally disordered offenders referred to high security psychiatric hospital

More mentally disordered offenders (MDOs) are referred to secure psychiatric care settings than are accepted for admission. Psychiatrists working in different care settings may disagree on the appropriate level of security for MDOs, resulting in treatment delay. A pre-admission structured assessment of security needs for MDOs may facilitate agreement and access to care. To assess the predictive validity and reliability of a structured assessment of security need (OPRISK) in a prospective cohort of referrals to high security hospital. Operationalized criteria describing risk factors related to security need were used to develop OPRISK, an 18 item checklist. The predictive validity of OPRISK was assessed prospectively on the outcome of 140 referrals to Broadmoor high security hospital. Receiver operating characteristic curves of the predictive validity of OPRISK yielded an area under the curve of 0.765 (p < 0.001, 95% CI: 0.686-0.844). Internal consistency (>0.75) and inter-rater reliability (0.925) were high. OPRISK makes the evidence for an MDO's security needs explicit, aiding communication across service settings and improving access to care.

Diminished cooperativeness of psychopaths in a prisoner's dilemma game yields higher rewards.

Maladaptive social behavior is one of the defining characteristics of psychopathic personality disorder. Nevertheless, maladaptive social behavior has only rarely been observed among psychopaths in experimentally controlled situations. The authors assessed the behavior of criminal psychopaths from high-security psychiatric hospitals in a computer simulation of a social dilemma situation. The psychopaths showed a markedly higher proneness to competitive (i.e., noncooperative) behavior than did healthy adults from the general population. The odds ratio between defection and being a psychopath was estimated at 7.86 in the sample. The probability to choose selfish instead of cooperative behavior was significantly linked to the following subscales of the Psychopathy Personality Inventory-Revised (S. O. Lilienfeld & M. R. Widows, 2005): rebellious nonconformity, Machiavellian egocentricity, and the total score. On average, the psychopathic participants accumulated higher gain and more strongly exploited their counterpart than did the healthy participants.

The Violent Offender Treatment Program (VOTP): Development of a Treatment Program for Violent Patients in a High Security Psychiatric Hospital

There are growing numbers of offenders with a mental illness convicted of violent behaviors in both the penal and mental health systems. To date however, there have been limited effective treatments reported for this population. This article describes the development, delivery and outcome of a pilot treatment program developed to meet this need (VOTP) within high secure psychiatric services. The program is based on current literature and clinical experience combined to provide a comprehensive theoretical model. The program thus account for theoretical and therapeutic content as well as responsivity and other delivery issues. The program is structured and manualized, multi modal, and delivered in approximately 280 hours of group therapy plus a range of weekly individual work and support. Staff training is an essential component of the work. So far, promising results are forthcoming. They include reductions in behavioral manifestations of violence, a decrease in perceived level of risk and an increase in coping and interpersonal skills.

The Prediction of Imminent Aggression and Self-Harm in Personality Disordered Patients of a High Security Hospital Using the HCR-20 Clinical Scale and the Dynamic Appraisal of Situational Aggression

Drawing on recent advances in the violence risk assessment literature, this study tested the predictive validity of two structured measures designed to support risk related decision making, the HCR-20 and the Dynamic Appraisal of Situational Aggression (DASA), for the prediction of imminent aggression and self-harm in personality disordered patients of a high secure psychiatric hospital. For four months nursing staff completed daily assessments of patients using the DASA and the Clinical scale items from the HCR-20. On the following day they documented whether patients had behaved aggressively and/or self-harmed. Results revealed modest predictive validity, significantly better than chance, for both the prediction of imminent self-harm and aggression for both measures. Furthermore, these results suggest that personality disordered patients in a negative psychological state characterized by irritability, impulsivity and disagreeableness are at an increased risk of aggression and self-harm during involuntary psychiatric inpatient treatment and that this state is sensitive to structured risk assessment.

Sectioned offenders presenting with enduring mental illness: a study exploring behaviors indicative of bullying

Logit and logistic regression analyses were employed to explore the nature, extent and predictors of behaviors indicative of "being bullied" and of "bullying others" in a sample of 125 adult male offender-patients sectioned for enduring mental illness and detained within a high-secure psychiatric hospital. The study addresses the lack of research into this specialized population to date, with a subsidiary aim of comparing the results directly with a previous study conducted with a population of adult male personality-disordered offender-patients (n = 53). Participants were required to complete a self-report behavioral checklist (Direct and Indirect Patient behavior Checklist-Hospital version Revised). The prediction that indirect (subtle) aggression would be reported more frequently than direct aggression was supported in relation to perpetration estimates, with evidence such aggression was also more prevalent among personality-disordered than mentally ill offender-patients. As predicted verbal aggression was the most commonly reported direct behavior. Although it was predicted that those perpetrating aggression would present with increased experience with secure settings this was only supported with regard to bully-victims. Contrary to the prediction made, those victimized did not present with less experience of secure settings. Consistent with the hypothesis, bully/victims were predicted by increased negative behavior toward staff and hospital rules. The results are discussed in relation to the environment in which the aggression is taking place with the implications for practice and future research outlined.

The High Secure Psychiatric Hospitals’ Nursing Staff Stress Survey 3: Identifying stress resistance resources in the stress process of physical assault

The present paper forms part of the High Secure Psychiatric Hospitals’ Nursing Staff Stress Survey and explores the causal role of generalized and specific stress resistance resources (SRRs) in the stress process following physical assault. Confidential self-report questionnaires were administered to all nurses working in English and Scottish High Secure Psychiatric Hospitals. A total of 636 nurses responded to questionnaires on physical assault, other relevant stressors, SRRs, and psychological distress as measured by the GHQ-12. Data were analysed using univariate and multivariate hierarchical regression analysis. Self-esteem, self-confidence, and coping met the definitional criteria of generalized SRRs. Findings on social support from outside work suggested a mediating role of this variable. Furthermore, manager support could be identified as a specific SRR that moderated effects of physical assault on psychological distress: assaulted nurses having a supportive manager scored lower on psychological distress than non-assaulted nurses having an unsupportive manager. It is concluded that, at a conceptual and empirical level, the current approach yields advances in terms of how generalized and specific SRRs contribute comparatively to alleviate high levels of psychological distress by testing additive, mediator, and moderator models, thereby achieving an increase in explanatory power of the stress process model as compared to previous research.