Secure Care Research Articles

On the Outskirts of the Charmed Circle\u2014Challenges and Limitations of Sexual Health Promotion to Young People in Secure State Care

ObjectivesYoung people on the verge of, or in, secure state care or incarceration have reduced general and sexual health. The promoting of sexual health among young people in secure state care is therefore a responsibility for both the state-run agency responsible for this care and for the professionals who work there.MethodsThis position paper discusses sexual and reproductive health and rights (SRHR) for young people in secure state care in Sweden. Four previous studies on sexual health of young people in secure state care are revisited, and governmental policy documents are examined.ResultsYoung people in secure state care face many threats to their sexual and reproductive health and rights. Some of these threats originate with the institutional placement itself and the lack of knowledge among the staff. Clashes on various levels between the subjectively desired (young people seeking pleasure from sex, alcohol, or other drugs) and the societally desired (sexual health, minimal alcohol use, and no drug use among young people) are described. In addition, clashes are seen between young people who want to be like everyone else in their social context and the staff with a mission (i.e. job description) to readjust young people into adopting socially accepted behaviour.ConclusionI argue that young people in secure state care have sexual experiences that are marginalized and placed on the outskirts of the charmed (sexual) circle of societally accepted sexual behaviour. In addition, their experiences are surrounded by silence, a silence sustained by both young people and professionals. The readiness of professionals to handle SRHR for young people in secure state care in a knowledge-based and non-judgemental fashion is crucial. Future research should focus on this readiness and have the needs and wishes of young people as its departing point. Although the article involves a local context, it may be of interest to a wider audience, as the placement of young people in secure state care and other forms of incarceration occurs worldwide.

Borderline personality disorder and violence.

This paper aims to provide a selective review of the co-occurrence of borderline personality disorder (BPD) and violence, a much less explored aspect of aggression with this cohort. Violence in BPD patients is expressed particularly towards intimate partners and known persons, usually in the homes of perpetrators. Anger, impulsivity and avoiding abandonment are traits associated with violence while suicidal behaviour, identity disturbance and affective instability are not. These patients are disproportionately found in higher levels of secure care although most violence occurs in the community. In males it is more likely driven by substance use, often at transition from adolescence to adulthood, while more severe borderline pathology is implicated in women. Early identification of an at-risk cohort is recommended with development of collaborative safety plans with patients that include identification of a 'risk signature' that guides risk management. A multi-modal approach using risk management protocols with availability of contingency plans within a multi-agency forum in a local context is recommended.

Disability, cash transfers and family practices in South Africa

Relative to other low and middle-income countries, South Africa provides a generous set of cash transfers (social grants) targeted at people with disabilities. This article explores the influence of disability-related grants on family practices and configurations, care arrangements and household composition in the Western Province of South Africa. The article draws on the findings of two studies: 1) an ethnographic study of disability grant recipients and applicants in a low-income Cape Town community and; 2) a study of interactions between healthcare staff, disability grant applicants and their families. Findings show that disability grant income is shared within households and the contribution of a stable income provides opportunities for people with disabilities to exercise agency, be seen as valuable household members and secure care and support from other household members. However, conflicts may arise over how income is shared and may lead to the extortion, abuse and neglect of people with disabilities, particularly in cases of severe disablement. Given the lack of adequate social provisioning for those who are able-bodied and unemployed, disability also becomes highly valued in households and the potential suspension or cancellation of a grant can interfere with adherence to treatment. The study emphasises the influence of policy structures and economic conditions on household dynamics and care outcomes and contributes to the sparse international evidence-base on the role that disability welfare benefits play in household dynamics and care outcomes.

Trauma Therapy: Exploring the Views of Young People in Care

ABSTRACT Young people living in residential care are more likely to have experienced past abuse, neglect, and adversity that result in the experience of trauma. Their subsequent behavior can present challenges to care-givers and hinder their engagement in services designed to help them understand and manage such experiences. This research aimed to explore young people’s views on what traumatized youth need from therapists to help them understand and respond to their experiences. Six young people aged 14 to 17 years old, residing in residential and secure care in the United Kingdom, were interviewed. Thematic analysis found three global themes related to the need for therapists to; involve young people in decision-making, take time to build trusting relationships, and create the right environment for treatment. Additionally, the findings indicated that alternatives to trauma therapy could be useful, which did not necessarily involve trauma exposure, and that this could be facilitated by primary care-givers as well as therapists, implying a need for more structured and integrated approaches between multi-disciplines involved in the residential care of young people. Young people’s views can assist in the development and design of future trauma-informed and trauma-focused treatment services within residential care settings.

Positive Behavioral Interventions and Supports in Secure Care Juvenile Justice Settings: Feasibility and Sustainability

The success of positive behavioral interventions and supports (PBIS) in typical schools has led to interest in applying PBIS in alternative settings, including secure care programs for incarcerated juveniles. PBIS holds promise for positively impacting youth behavior in this context. In this discussion article, we describe unique characteristics of secure care and strategies to enhance PBIS implementation and sustainability.

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

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

Secure care: more harm than good.

Secure care: more harm than good.

Cultural sensitivity in paediatric nursing care: a concept analysis using the Hybrid method.

Cultural sensitivity is a core concept to establish awareness and knowledge about various ethnicities, cultures, genders and additional diversity characteristics to understand individual's requests and respond appropriately to them. A need for further development of the concept is warranted, especially in the context of paediatric nursing. The purpose of this paper was to determine the main elements of cultural sensitivity in the context of paediatric nursing in Iran. The Hybrid method was implemented consisting of three phases: theoretical, fieldwork and final analysis. In the theoretical phase, articles from 2007 to 2017 were reviewed for relevance. In the phase of fieldwork, 25 nurses and nine parents were interviewed to explore the aspects of cultural sensitivity in paediatric nursing. The interviews were transcribed, and content analysis was conducted. In the final phase, an overall analysis of the two previous phases was performed. In the theoretical phase, the following attributes were determined: cultural encounter and awareness, acceptance of cultural diversity and designing programmes in accordance with family culture. The fieldwork phase explored three themes of intercultural encounters, intercultural communication and adapting the care plan with family culture. The final synthesis yielded that sensitivity to family requests and beliefs, effective intercultural communication and integration of family culture with the care plan are the main elements of cultural sensitivity in Iranian paediatric nursing. With a deeper understanding of the term cultural sensitivity, nurses will have a foundation to improve paediatric nursing care and align the care plan with the patient's culture to provide trust, child/parent participation, secure care, effective communication and satisfaction. Since the concepts are the building blocks that underpin theory, the present concepts identified can help to serve as the foundation for the development of a theoretical model.

Sustaining PBIS in Secure Care for Juveniles

Sustaining PBIS in Secure Care for Juveniles

Ageing in forensic psychiatric secure settings: the views of members of staff

ABSTRACTBackground: Although the prevalence of older patients in forensic psychiatric services is increasing, research around service provision for this population is very limited. We aimed to gather the views of members of staff on how well secure services are meeting the challenges of an ageing population.Methods: Three focus groups were carried out with 13 members of staff working with older patients in secure services. A topic guide, based on the research team’s previous research, guided the sessions. The focus groups were audio-recorded, transcribed and analysed through thematic analysis.Results: Two themes were identified: (1) Identifying patients’ needs, which focused on how promptly any emerging issues in the older patients are identified and reported; (2) addressing patients’ needs, which focused on how the unique needs of the older patients are addressed, once established.Conclusions: There are unique age-related issues that may have an impact on the older patients’ opportunities for recovery, including a lack of specialist training for members of staff, prolonged stay in secure care and a limited number of age-relevant activities. Far from optimal, provision requires improvement through the active involvement of the primary stakeholders.

Secure care: more harm than good.

KEY POINTS Many who overdose on drugs in British Columbia are youth under the age of 19 years,[1][1] and calls for “secure care” legislation have intensified. Secure care legislation would legitimize the detention and forced care of youth who are deemed to be at immediate risk of serious

Validation of the Massachusetts Youth Screening Instrument with a looked after population.

The Massachusetts Youth Screening Instrument-version 2 (MAYSI-2) was developed to help identify mental health needs of young people admitted to youth detention centres. Only one study has applied the tool to a UK population and none have looked at young people who live in residential and secure care in Scotland. This study aimed to assess the validity of the MAYSI-2 in Scotland with a looked after and accommodated population. Boys and girls in a large education and care centre were asked to complete the MAYSI-2 within 72 hours of being accommodated. A total of 168 males and 69 females with a mean age of 15 completed the tool. Substantial levels of mental health need were identified. Girls appeared to have higher needs on all areas, bar alcohol and substance misuse. The MAYSI-2 had good internal consistency and exploratory factor analysis showed good overlap with the tool's original factor model. As a result, there can be more confidence in the validity and consistency of the tool with this population. This is also further evidence of the high need of this population, particularly girls.

Measuring Repression in Residential Youth Care: Conceptualization, Development and Validation of the Institutional Repression Questionnaire

Repression in residential youth care institutions threatens youth’s positive development. When youth experience arbitrary use of power, structure, or coercion, this may cause demotivation, reactance or aggression, and diminished chances of rehabilitation in youth. Because institutional repression may be hard to recognize, a valid and reliable measurement instrument is necessary to signal repression in residential institutions. This article outlines the conceptualization, development and validation of the Institutional Repression Questionnaire in a sample of 180 youth (aged 12–24, 32% female) staying in open, secure, and forensic residential youth care institutions. The Institutional Repression Questionnaire is a self-report questionnaire, designed to measure five dimensions of repression: abuse of power, injustice, lack of autonomy, lack of meaning, and dehumanization. The multicomponent structure was confirmed in a confirmatory factor analysis, resulting in 24 items in five subscales: Abuse of Power, Justice, Lack of Autonomy, Meaning, and Humanization. One open-ended question is part of the questionnaire to invite youth to disclose more extreme cases of repression. Convergent validity was established via correlations between the Institutional Repression Questionnaire and the Prison Group Climate Inventory—as a measure of living group climate in residential institutions—and the Basic Psychological Need Satisfaction and Frustration Scale-Intellectual Disability—as a measure of self-determination. The five Institutional Repression Questionnaire subscales demonstrated good internal consistency. The study provides preliminary evidence to support validity and reliability of an adolescent self-report questionnaire of perceived institutional repression as a multidimensional construct. Residential youth care institutions can use outcomes of the Institutional Repression Questionnaire to improve their living group climate.

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

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

Older adults in secure mental health care: health, social wellbeing and security needs measured with HoNOS-secure across different age groups

ABSTRACTThe number of older offenders is rapidly increasing in the United Kingdom and some older adults with mental health issues are referred to secure care services. It is therefore important to understand their unique characteristics in order to develop services based on their individual needs rather than chronological age. This study explored wellbeing and security needs of younger and older patients admitted to a secure psychiatric hospital. HoNOS-secure assessment at admission and discharge was extracted and used to build an anonymous data-set. Group comparison and score change during admission were conducted for six age groups: 18–24, 25–34, 35–44, 45–54, 55–64 and 65+. Younger patients improved on most measures whereas older patients aged 55–65+ showed little improvement or deterioration over time. This finding suggests that the subscales are sensitive to age difference although the needs measured by HoNOS-secure are less likely to inform the decision to discharge.

Positive Behavior Interventions and Supports Implementation in Secure Care Juvenile Justice Schools: Results of a National Survey of School Administrators

Despite the prevalence of Positive Behavioral Interventions and Supports (PBIS) for addressing student behavior in public schools, little information exists on the extent and consistency of implementation efforts in secure juvenile justice (JJ) schools. Reports of fidelity to core PBIS processes and components are needed to determine the ubiquity of comprehensive efforts and link implementation to outcomes. All 301 JJ schools in the United States were sent a survey and we report on responses from 143 (47.5%) principals. The survey focused on (a) use of multitiered systems of behavior supports; (b) organizational leadership and training; (c) expectations and consequences; (d) behavior response, monitoring, and oversight; and (e) crisis prevention and management. Approximately 84% of respondents identified alignment with a multitiered framework for behavioral supports. However, fewer supports were available to youth with more serious behavioral needs (i.e., at Tiers 2 and 3). Additional results, implications, and recommendations are provided.

Contested Vulnerability: A Case Study of Girls in secure care

Figures from 2015 show that two hundred and five children entered secure accommodation from England and Wales. 47% were placed because they were on remand or sentenced for committing a serious offence. 43% were placed by social services under a child welfare order. The remaining 10% were secured by their local authority on criminal justice grounds. This paper uses the example of girls in secure care to explore understandings that are applied to young people considered ‘vulnerable’ and ‘troublesome’ simultaneously. While policy around secure accommodation claims that it offers a therapeutic intervention, to help young people work through their problems and learn appropriate coping mechanisms, it also keeps them ‘safe’ by physically locking them away from the world in which they have been entrenched. Using detailed ethnographic fieldwork, this paper explores the experiences of girls living in a setting usually exempt from scrutiny and showcases their views of being ‘worked with’ in an institution designed to enable reform. Significantly, findings show that girls rejected the ‘vulnerable’ label that was ascribed to them and instead felt that vulnerability was better defined by life experience instead of age. By examining girl's own perspectives of their complex pathways into secure care, this paper will contest the binding of childhood and vulnerability and argue that such an act disenfranchises girls from the services that are designed to help them.

The maltreatment-violence link: Exploring the role of maltreatment experiences and other individual and social risk factors among young people who offend

ObjectiveThis study investigated the extent to which violent offending in a population of young people detained in secure care facilities is related to variations in child maltreatment after controlling for other known individual and social correlates of crime. MethodOfficial child protection and youth justice records and survey information for 1819 young people were analyzed. Measures included: maltreatment factors (including type, timing and recurrence); out-of-home care placement factors (including type, age at first placement, stability and duration of placements); social factors (including family and peer risk indicators); and individual factors (including factors relating to intelligence and education, substance use, mental health problems, and behavior). Gender and cultural background were also investigated as potential moderating factors. Logistic regression was used to determine the independent effect of maltreatment factors on violent convictions in the presence of other risk factors. ResultsPersistent maltreatment was a consistent predictor of violent convictions. Other independent predictors included: aggression, anger, Indigenous status, and male gender, with household conflict also approaching significance. ConclusionCollaborative and integrated responses from both child protection and juvenile justice may be needed if comprehensive violence prevention strategies are to be developed for young offenders.

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.