Medium Secure Unit Research Articles

Addressing substance misuse in medium secure settings in the UK and Ireland – a survey of current practice

Purpose – Rates of co-morbid substance misuse are high within forensic populations. Addressing these problems should be a priority as mental disorder with co-morbid substance misuse is associated with worse outcomes, including rates of re-offending and violence recidivism. A study undertaken in 2006 by the Royal College of Psychiatrists’ Research and Training Unit concluded that the provision of substance misuse treatments in medium-secure units (MSUs) at that time was inadequate. The purpose of this paper is to investigate how services may have developed since then to inform discussion over future development and best practice. Design/methodology/approach – A postal survey, supported by the Quality Network for Forensic Mental Health Services, was sent to 62 MSUs across the UK and Ireland. This questioned prevalence, interventions and staff training in substance misuse. Findings – In total, 41 units responded (66 per cent). The data suggest rates of substance misuse within MSUs have reduced and provision of treatment has increased in recent years. The majority of MSUs provide a variety of interventions to address substance misuse and are internally resourced, in tune with current national guidance. However, the data suggest many MSU staff are not receiving adequate training in substance misuse treatments and some MSUs do not appear to have a cohesive strategy that would be consistent with best practice. Practical implications – This study provides an up-to-date overview of the provision of treatment for substance misuse within MSUs. Originality/value – There is no other source for this information, which will provide an invaluable reference point for services seeking to develop or improve their clinical services.

Evaluating service user community groups in forensic and neurodevelopmental units

Introduction: Often service user involvement in forensic mental health settings can fail to address service users' views in a systematic way and is more likely to be designed around organisational priorities. Method: Community meetings in six forensic medium–secure units and three neurodevelopmental (ND) units were compared. Using framework analysis, the study evaluated practice, in particular how staff and service users interacted and the issues raised at meetings. Data was collected from interviews, questionnaires and minutes of the meetings. Results: On average, meetings were more frequent in ND than in forensic units. Difficulties were reported in resolving issues due to factors including shift patterns, staff who could make decisions being unavailable, and policy and budget constraints. Forensic unit groups tended to focus on information and ND groups on activities and the ward environment. Complaints were more likely to be raised in forensic units than in ND units. Discussion: This study provides an insight into community groups and offers an insight into the realities of user engagement in community meetings.

Police National Computer Record Checks in Referrals to a Medium Secure Unit

Introduction The forensic history is a vital part of the assessment in patients referred to forensic services. It influences decisions made about risk and the link between illness and offending behaviour. Doctors should view the police national computer, (PNC) record in all assessments of referrals. Objectives To establish whether PNC records are available to doctors conducting forensic psychiatric assessments of new referrals at a medium secure unit (MSU). Aims Establish what proportion of patients referred to a MSU in London had a PNC record present at the time the assessment report was presented to the admissions panel. Methods The admissions panel of a MSU in London has kept data on all assessments carried out since 2011. All of this data was reviewed to see what proportion of patients had a PNC record present at the time the assessment report was presented to the admissions panel. Results In total there were 186 patients. 21 of these were women. 165 of these were men. 59% of the assessments had a PNC record present. In 19% of assessments a PNC was not requested. In 18% it was requested but not available. In 4% it was deemed not necessary. Conclusions A PNC record was not available in 41% of forensic assessments carried out by a large forensic service in London. In 19% of these cases a PNC had not been requested. Suggested recommendations are that the PNC is requested at the time that the referral is received by the trust.

Clinical characteristics and outcomes on discharge of women admitted to a Medium Secure Unit over a 4-year period

There are limited data on women in Medium Secure settings. This study aimed to address this by assessing the characteristics of 45 consecutive admissions to the female ward of a Medium Secure Unit in the United Kingdom over a four-year period. Data on demographics, clinical outcomes and from HONOS-Secure/HONOS and HCR-20 assessments were prospectively collected. Psychiatric diagnoses were recorded using ICD-10 criteria. Data on quality of life from WHO-QoL-BREF surveys were analysed. There was a high proportion of ethnic minorities (57.8%), high rates of childhood and adult abuse and low socioeconomic status. 62.2% of the patients had schizophrenia, 57.8% had multiple diagnoses. The median length of stay at discharge was 465.5days. There were statistically significant reductions in rates of self-harm and HoNOS-Secure/HoNOS and HCR-20 scores following intervention. Scores on WHO-QoL-BREF compared favourably to a large-scale sample with mental health difficulties. Many characteristics of this sample were comparable to samples from similar populations. However the particularly high proportion of ethnic minorities suggested that the profile of our patients differs from nationwide samples. Intervention by our service was associated with reduced self-harm and improvements in well-defined clinical outcomes and quality of life measures using validated scales.

Psychiatric diagnosis and differential risks of offending following discharge

Psychiatric diagnosis is not considered a risk factor for offending following discharge. However, treatment interventions and aftercare are strongly influenced by clinical primary diagnosis. We compared differential risks of reoffending of patients falling into six primary diagnostic categories following discharge from Medium Secure Units in the UK: schizophrenia/schizoaffective disorder; delusional disorder; mania/hypomania; depressive disorder; organic brain syndrome; personality disorder. We followed up 1344 patients, on average 6.2years (SD=2.1) at risk, discharged from 7 of 14 Regional Medium Secure services in England and Wales. Outcomes were period prevalence, incidence, and cumulative probability of criminal conviction. Established demographic and criminal history predictors of reoffending were observed across different diagnostic categories. Risks of all offending were increased for personality disorder, violence/acquisitive offending for delusional disorder, sexual offending for mania/hypomania and violence/acquisitive offending for organic brain syndrome. Patterns of risk over time differed markedly between categories of mental disorder. Most patients with personality disorder who offended violently did so within 4years of discharge. A subgroup with delusional disorder demonstrated increased risk of violent offending 5years after discharge. Differential risks of reoffending are observed between different diagnostic groups. Clinical diagnosis should be included together with established risk measures in risk management following discharge. Close supervision of patients with personality disorder should begin immediately after discharge when risks of reoffending are greatest. For delusional disorder further investigation is needed into the marked increase in risk of violence after 5years.

Prediction of treatment outcomes for personality disordered offenders

Purpose – Evidence has shown associations between personality disorder (PD) and poor treatment outcomes. The purpose of this paper is to: first, establish which risk assessment method (i.e. structured professional judgement or actuarial) is most reliable for predicting treatment outcomes for individuals with PD. Second, determine whether individuals identified as high risk are more likely to have poorer treatment outcomes. Third, determine if engagement in treatment helps to reduce risk assessment scores. Design/methodology/approach – In total, 50 patients were recruited from a medium secure forensic PD service. Their risk was assessed using one structured professional judgement instrument (the HCR-20) and one actuarial instrument (the RM2000). The study used a retrospective cohort design. Findings – Overall, the HCR-20 was a better predictor of treatment outcome than the RM2000. Personality-disordered offenders with high HCR-20 scores are at an increased risk of adverse treatment outcomes. Research limitations/implications – This investigation used a small, non-randomised sample of male patients with PD at one South East England medium secure unit. The data were over-represented by white British males. Future research should compare PD offenders with non-PD offenders to investigate what factors best predict poorer treatment outcomes. Originality/value – The findings indicate that structured professional judgement approaches are more effective predictors of risk than actuarial measures for assessing patients with PD. This study therefore adds value to forensic services and to the risk assessment debate.

A cross sectional survey examining the association between therapeutic relationships and service user satisfaction in forensic mental health settings.

BackgroundThis small-scale study examines an often neglected patient group (service users in forensic mental health settings). The research investigates their therapeutic relationship with staff and which therapeutic relationship factors are associated with their level of satisfaction with services.MethodsA cross sectional survey was undertaken in two medium secure units in the UK with seventy seven participants completing self-report measures examining service user satisfaction with services and their therapeutic relationship with staff. Multiple regression analysis was used to identify the main predictor variables associated with satisfaction with the service provided.ResultsThe respondents had a generally positive view of services and also of their therapeutic relationships with staff. However, the therapeutic relationship scores were lower than those recorded in community samples. One predictor variable was significantly associated with service user satisfaction; feeling respected and well regarded.ConclusionsThe therapeutic relationship domain of being respected and well regarded by staff was identified as the most significant factor among the therapeutic relationship domains when examining the association with satisfaction with services. The important role mental health clinicians play in enabling service users to recognize they are being treated respectfully is noted as service users judge the degree of honesty, caring and interest that staff show in them. Staff also need to be available and accessible while having good listening and information giving skills. The importance of having both positive therapeutic relationships and service user satisfaction in forensic settings is also discussed.

Discharges to prison from medium secure psychiatric units in England and Wales

Early findings from a national study of discharges from 32 National Health Service medium secure units revealed that nearly twice as many patients than expected were discharged back to prison. To compare the characteristics of those discharged back to prison with those discharged to the community, and consider the implications for ongoing care and risk. Prospective cohort follow-up design. All forensic patients discharged from 32 medium secure units across England and Wales over a 12-month period were identified. Those discharged to prison were compared with those who were discharged to the community. Nearly half of the individuals discharged to prison were diagnosed with a serious mental illness and over a third with schizophrenia. They were a higher risk, more likely to have a personality disorder, more symptomatic and less motivated than those discharged to the community. Findings suggest that alternative models of prison mental healthcare should be considered to reduce risks to the patient and the public.

Management of treatment resistant schizophrenia in medium secure care

Thirty-one percent of patients within a male medium secure unit (MMSU) were identified with treatment resistant schizophrenia. Almost half of these patients had not received clozapine treatment at least once during the course of their treatment history. The authors recommend that early identification of these patients and the appropriate use of therapeutic treatments, including clozapine, could lead to better outcomes for patients and significant cost savings for the NHS.

A survey of the provision of family therapy in medium secure units in Wales and England

A cross-sectional survey design was utilised to capture a snapshot of the provision of family therapy in medium secure units (MSUs) across Wales and England during 2013. Semi-structured interviews were administered via telephone interview with 39 MSUs. Information pertaining to the main research question was also gathered from a further 10 via email follow-up. Over a third of responding MSUs in Wales and England were offering family therapy, with team members being appropriately qualified and receiving regular supervision. Systemic psychotherapy was the most prevalent approach to working with families and it is suggested here that systemic psychotherapy fits well with the complexity and uniqueness of working with families in secure contexts.

An exploration of caring for female mentally disordered offenders

The challenges of caring for female offenders with a mental disorder are significant. This study provides an exploration of forensic nurses’ motivation to care for this patient group. A small qualitative study was undertaken with four experienced forensic nurses working on a medium secure unit in the NHS in England. In-depth semi-structured interviews were conducted, digitally recorded and transcribed. Through a qualitative content analysis, three key themes were identified that impacted on nurses’ motivations to care: job satisfaction, building the therapeutic relationship and the importance of support. A framework for practice is proposed to illustrate the impact of well-supported staff on patient care.

Bullying behaviours among mentally disordered offenders in a medium secure unit

Purpose – The purpose of this paper is to explore the nature and prevalence of bullying behaviours and victimisation experiences among mentally disordered offenders within a medium secure unit (MSU). Design/methodology/approach – In all, 35 adult male patients completed the Direct and Indirect Patient behaviour Checklist-Hospital Version (DIPC-H). Findings – Indirect aggression was reported more frequently than direct aggression, although there was no statistically significant difference between the prevalence estimates. The most prevalent DIPC-H categories were the pure victim and not involved categories followed by bully/victim and pure bully. Membership of the pure bully category was predicted by being on a particular ward. Research limitations/implications – Given that the study was a preliminary investigation into the nature and prevalence of bullying behaviours in a MSU, the sample size is limited. Consequently, it is difficult to generalise the findings. It would be useful for future research to focus on differences between levels of security using larger sample sizes to enable a greater understanding of the prevalence of bullying in secure settings and associated factors. Practical implications – Further evidence is provided by the current research that indirect bullying and victimisation behaviours are reported more frequently by patients. The importance of anti-bullying procedures and interventions in secure settings is emphasised and recommendations that can be applied across various forensic settings are described. Better-informed interventions can then be implemented with the aim to manage bullying behaviours in secure settings. The one “pure bully” in the current study was on a rehabilitation ward. This highlights that such behaviours occur on lesser secure wards and serves as an important reminder to ensure that staff do not become complacent. Originality/value – As there is only one published study to date that has focused on bullying behaviours in a MSU, the current study will contribute to the dearth of literature in this area and assist professionals working in secure settings to better understand the nature and prevalence of bullying behaviours among mentally disordered offenders.

“I couldn’t have done it on my own.” Perspectives of patients preparing for discharge from a UK high secure hospital

Purpose – Discharge preparation from high to medium levels of security has received little attention from researchers to date, but is a critical stage in a patient's pathway. This paper aims to capture the perspectives of patients who are preparing to move on from high to medium security. Design/methodology/approach – Nine patients who were in the “discharge preparation” stage of their pathway were interviewed to capture their perspectives on the process. Interview transcripts were analysed using thematic analysis. Findings – Nine themes were identified as representing the patient interviews: trust and support, feeling empowered, journey of self-acceptance, skilling-up, getting to know the Medium Secure Unit (MSU), feeling disempowered and unvalued, issues with the system, anxiety about endings, and stigma and society. Originality/value – This paper gives voice to patients across clinical directorates at a UK high secure hospital regarding their perspectives on what has helped and hindered their discharge preparation. It presents some new findings, and recommended good practice, which should be of use to clinicians and managers who wish to enhance discharge preparation interventions for patients within high secure services.

EPA-1612 - Ascertaining drug and alcohol history in new admissions to a forensic medium secure unit

Introduction A history of drug and alcohol use influences various aspects of inpatient care. It is important to ascertain the history of drug and alcohol use in new admissions. This knowledge ensures the appropriate detoxification of patients. It also allows the management of various risks such as the risk of violence, of escape, of drugs being brought onto the ward and of drug use amongst other patients. It can explain the lack of therapeutic progress in patients. Objectives To ascertain whether new patients admitted to an acute ward on a medium secure unit in London are being asked about their drug and alcohol usage history. Aims To establish what proportion of 18 male inpatients on a medium secure unit have their drug and alcohol history documented in their admission notes. Methods The notes of all 18 patients on an acute ward in a medium secure unit were scrutinised. An audit tool was used to record whether the admission notes contained an entry about the history of drug and alcohol use. Results There were 18 male patients. Four were under a section 3, four under a section 47, four under a section 48, one under a section 38, five under a section 37 of the Mental Health Act 1983. Only 5 of 18 patients had been asked about their history of drug and alcohol use on admission. Conclusion An important part of the history is being missed in a large proportion of new male admissions to a medium secure unit.

Substance use amongst mentally disordered offenders in medium security: prevalence and relationship to offending behaviour

Purpose – Substance use contributes to the development of criminogenic behaviour and mental health problems. However, the extent and severity of substance use and the relationship to offending in mentally disordered offenders (MDOs) admitted to regional medium secure units has received relatively limited research attention. Design/methodology/approach – Case note reviews (n=57) and semi-structured interviews (n=21) of past substance use levels, substance use problems and forensic history were conducted at a medium secure unit in South East England. Findings – Results highlighted the high prevalence of substance use among MDOs, especially when determined by self-report. At least one-third (case note review) or almost half (self-report) used alcohol at the time of their index offence, although many failed to recognise use as problematic. Significant correlations were found between heavy past use of alcohol and use of alcohol at time of offending. Past heavy use of alcohol significantly predicted whether or not the individual was convicted of a violent offence. Research limitations/implications – The small sample from one area limits the generalisability of findings as substance use demographics vary. Methodological shortcomings were noted when comparing data from self-report and case note information. Retrospective recall bias may influence past perceptions of substance use. Practical implications – These preliminary findings indicate the importance of assessing substance use in MDOs and considering its relationship to offending behaviour in treatment and risk management. Originality/value – Although anecdotally substance use is known to be high and likely to be related to offending behaviour amongst MDOs, there is little previous research highlighting this.

Assessing Short-term, Dynamic Changes in Risk: The Predictive Validity of the Brockville Risk Checklist

In the present study, we examined the predictive utility of the Brockville Risk Checklist (BRC), a structured assessment tool for clinical care planning, using a semi-parametric regression technique. We examined BRC scores and the frequency and type of incidents (aggression, noncompliance, etc.) over 13 assessments for 121 psychiatric patients at a medium-secure forensic unit. Most patients were male (95%), on average 40.9 (SD = 13.0) years old, and diagnosed with a psychotic disorder (78%). Generalized estimating equation (GEE; Liang & Zeger, 1986) modeling was used in this study to determine if changes in dynamic risk scores over time predicted outcomes (presence or absence of an incident) during the approximately six-week follow-up period. Results showed that scores on the Harm to Others scale assessed at one case conference significantly predicted changes in aggressive and total incidents recorded in the subsequent case conference. The BRC shows promise as a dynamic measure of inpatient aggression, predicting verbal or physical incidents an average of six weeks later.

Service attachment: The relative contributions of ward climate perceptions and attachment anxiety and avoidance in male inpatients with psychosis

It has been suggested that mental health services can help meet the attachment needs of inpatients and improve patient outcomes through the provision of a 'secure base'; however, what defines the latter is unclear. Perception of ward climate might be a useful indicator. The aim of this study was to examine whether inpatient perceptions of the ward climate, which is partly under the control of the service, or inpatients' own personal levels of attachment anxiety and avoidance are more associated with their attachment to their service. Seventy-six men diagnosed with a psychotic illness, who were residents in one of four regional medium-security units in England, completed questionnaire measures of service attachment, personal attachment style and ward climate. Ward climate was more strongly associated with service attachment than personal levels of attachment anxiety and avoidance. The most important aspect of ward climate for service attachment was the depth and influence of staff support for the inpatients. Although patient characteristics are important influences on development of service attachment, ward climate is also important. The latter may be easily and reliably monitored with a brief questionnaire. Strategies to enhance and maintain its positive components are likely to be important for progress with forensic hospital inpatients who have a psychotic illness.

Transformations of self and sexuality: Psychologically modified experiences in the context of forensic mental health

Forensic mental health inpatients in medium-secure settings have a limited capacity for sexual expression during their stay in hospital. This is due to a number of factors, including a lack of willingness on behalf of staff to engage with sexual issues, as a result of safety fears and ambiguity regarding the ability of the patient to consent. Furthermore, UK forensic medium-secure units do not provide conjugal suites for patients to have sexual relations, with their spouse or other patients. To date, there is no empirical research on how forensic psychiatric patients (or service users) manage their sexuality, while in hospital and when released into the community. Here, we present an analysis of semi-structured interviews with patients at a UK medium forensic unit, in order to explore these issues further. More specifically, we examine how the public exclusion of sexuality from these units results in sexuality being experienced as sectioned off or amputated, such that a new form of sexuality emerges, one that has been cultivated by the psychologically informed practices operating within the unit. This process, we argue, produces a psychologically modified experience, a new form of self-relation that continues to modify when released into the broader ecology of the community.

Predicting Institutional Violence in Offenders with Intellectual Disabilities: The Predictive Efficacy of theVRAGand theHCR‐20

There is a developing evidence base to support the use of risk assessment instruments in offenders with intellectual disability (ID). The aim of this study was to try to develop this literature with the inclusion of a control group of mentally disordered offenders without an ID, using the HCR-20 and VRAG. The VRAG and the HCR-20 were completed for a group of offenders with an ID (n=25) and a control group (n=45), in four medium-secure units across the UK. The outcome measure was physical aggression measured over 6months. Both instruments consistently produced large effect sizes predicting any physical aggression and severe physical aggression. The structured clinical judgement based on the HCR-20 was especially good. The HCR-20 and the VRAG have excellent predictive efficacy in offenders with an ID. A structured clinical judgement based on the HCR-20 was especially predictive.

Lived experiences of recalled mentally disordered offenders with dual diagnosis: a qualitative phenomenological study

The lived experience of mentally disordered offenders with dual diagnosis was the focus of this study. Interviews with five recalled service users from a medium secure unit in England were subjected to an interpretative phenomenological analysis. Five themes were identified relating to identity, control, autonomy and recovery. Clinical implications include increasing service users’ awareness of available post-diagnosis identities, which meet the needs of individuals’ lived contexts and promotion of recovery-oriented care in forensic settings.