Secure Forensic Settings Research Articles

“Back off means stay with me”. Perceptions of individuals with mild intellectual disability or borderline intellectual functioning about the group climate in a secure forensic setting

Purpose The purpose of this study is to provide an in-depth account of how individuelas with a mild intellectual disabilitiy or borderline intellectual functioning (MID-BIF; IQ 50–85) perceive their group climate in a secure forensic setting. Giving voice to these service users may provide relevant insights for secure forensic settings. Design/methodology/approach The interpretative phenomenological analysis was used to explore what individuals with MID-BIF experience with regard to their group climate. Findings In the interviews about the four domains of group climate (i.e. repression, support, growth and atmosphere), five overarching dimensions appeared, namely, autonomy, uniformity, recognition, competence and dignity. Depending on the person and the (treatment) context in which he/she resides, these five dimensions relate to all four factors of the group climate instrument. Originality/value From the perspective of individuals with MID-BIF, this study contributes by providing a framework to “fine-tune” group climate on five dimensions. Training socio-therapists to be sensitive to interpret ambiguous signals on these dimensions can contribute to optimizing group climate in secure forensic settings.

Group climate, aggressive incidents and coercion in a secure forensic setting for individuals with mild intellectual disability or borderline intellectual functioning: A multilevel study.

BackgroundThis study examines associations between group climate, aggressive incidents and coercive measures in adults with mild intellectual disability or borderline intellectual functioning (MID‐BIF) of a secure forensic setting.MethodParticipants (N = 248) were interviewed about their perception of group climate utilizing the Group Climate Instrument. Data on aggressive incidents and coercive measures were retrieved from the facilities’ electronic database. A multilevel structural equation model was fitted in which variability in perception of group climate within and between living groups was examined.ResultsAn open and therapeutic group climate was associated with lower levels of aggression within and between groups. A higher number of aggressive incidents were significantly associated with a higher number of coercive measures.ConclusionsThe findings have implications for the understanding of how group climate may play a role in reducing aggressive incidents at the living group in treatment of individuals with MID‐BIF in secure forensic settings.

Validating the Essen Climate Evaluation Schema modified for people with learning disabilities in a low-risk secure forensic setting.

Research has shown that an empowering and nurturing yet challenging work climate is beneficial for people receiving clinical services as it increases patient satisfaction, motivation, engagement, therapeutic alliance and functional improvement. Therefore, for inpatients, monitoring, encouraging and understanding ward climate holds considerable potential for improving forensic mental health services. To date, the most widely employed tool for ward-climate, the Essen Climate Evaluation Schema (EssenCES), has been evidenced as useful in medium and high security hospitals, but little tested with people with learning disabilities or in low security services. To establish the internal consistency and factor validity of the EssenCES, modified for easier reading, in a low secure hospital unit for people with learning disabilities. Language in the EssenCES was simplified and picture supplements added to facilitate comprehension. Patients completed the scale as part of their clinical routine, supported by National Health Service (NHS) employed psychology assistants. The research team, entirely independent of NHS staff, extracted data from the electronic records of purposively sampled residents in a low-secure forensic hospital setting for people with learning disabilities. Two hundred and twenty-seven records (70% men) were acquired. The EssenCES was shown to have good factor validity and retained the original three factor model including the subscales: therapeutic hold, safety and cohesion. One single-item from the 'therapeutic hold' subscale was removed to improve the internal consistency (p < 0.05). This study adds preliminary support for the use of the EssenCES (with removal of one item) in individuals with learning disabilities within low-risk secure forensic hospital settings.

An integrative review of nursing staff experiences in high secure forensic mental health settings: Implications for recruitment and retention strategies.

To identify the experiences of nursing in high secure forensic mental health settings that may affect staff recruitment and retention. Recruitment and retention of Registered Nurses is a vital international concern in the field of mental health. The high secure forensic setting presents unique challenges for the nurse. Studies of nurse's experiences in this setting have not previously been reviewed in the context of workforce sustainability pressures. An integrative review (Whittemore and Knapfl, 2005). A systematic search of data sources: MEDLINE (PubMed), PsycINFO, EMBASE, CINAHL, International Bibliography of the Social Sciences, Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, ProQuest Social Sciences Premium collection (IBSS, PAIS, and Sociological Abstracts), and Web of Science from inception to December 2019. Data extraction, quality appraisal, and convergent qualitative synthesis. Fifteen papers were selected for inclusion in the review, describing 13 studies. Six studies were quantitative, all cross-sectional surveys. There were seven qualitative studies, using a variety of methodologies. Four themes were identified: engagement with the patient group, the ward social environment, impact on the nurse, and implications for practice. When policymakers address workforce shortages in high secure forensic nursing they must take account of the unique features of the setting and patient group. Nurses must be adequately prepared and supported to function in an ethically and emotionally challenging environment. This study identified factors affecting workforce pressures in the speciality of forensic mental health nursing. Findings are of interest to national nursing policymakers and workforce leads in mental health service provider organizations, seeking to promote forensic nursing as a career option and retain nursing staff.

A Substance Use Treatment Programme for Mentally Ill Forensic Patients in an Australian Setting: A Pilot Study of Feasibility, Acceptability and Preliminary Efficacy

This study aims to evaluate the feasibility, acceptability and preliminary efficacy of an Australian-adapted Substance Use Treatment Programme (SUTP) among mentally ill offenders in an Australian secure forensic setting. A single-group non-controlled pilot trial was conducted. Four SUTP treatment groups were run simultaneously (n = 39) with sessions held weekly over 12 weeks. Feasibility was assessed by examining attrition, study retention and motivation for treatment, and measures of therapeutic alliance, client satisfaction and qualitative interviews were used to determine acceptability. Preliminary efficacy was assessed using self-report questionnaires implemented at baseline and post-intervention measuring drug related locus of control, confidence to resist substances in the future and beliefs about substance use. Low attrition, high levels of satisfaction and moderately positive levels of therapeutic alliance were found. Participants also demonstrated a significant shift towards an internal drug related locus of control upon completion of SUTP. SUTP is a promising intervention for mentally ill offenders with a history of substance use in Australian forensic services. A randomised controlled trial is warranted to rigorously evaluate the efficacy of SUTP in this setting.

Coping, mental health, and subjective well-being among mental health staff working in secure forensic psychiatric settings: Results from a workplace health assessment.

Given raised rates of patient suicide and violence in secure psychiatric facilities, staff in such settings are arguably at increased risk for burnout and reduced mental health. The present article responds to the recent U.K. National Institute for Health and Care Excellence (NICE) call to assess workforce well-being. This article held the following aims: (1) to quantify existing levels of mental health (i.e., depression, anxiety, distress, and posttraumatic stress) and subjective well-being (i.e., job satisfaction, life satisfaction, and four domains of burnout) and (2) to evaluate Coping Self-Efficacy (CSE) and Need for Affect (NFA) as factors associated with staff mental health and subjective well-being. We conducted a voluntary cross-sectional health needs assessment of forensic mental health staff (N = 170) between 2017 and 2018 from one National Health Service (NHS) Trust. Descriptive findings suggest staff possessed nonclinical average ranges of mental health symptoms. Subjective well-being findings showed burnout was relatively low, whereas job and life satisfaction were modest. Regression models demonstrated that (a) thought/emotion stopping beliefs were negatively associated with psychological exhaustion; (b) social support beliefs were positively associated with life satisfaction and job enthusiasm; (c) NFA Avoidance was linked with poor mental health and burnout, and; (d) NFA Approach was positively associated with two health subjective well-being indicators. Overall, assessment results suggest NHS forensic mental health staff reported relatively good health. Cognitive- and emotion-focused coping beliefs demonstrate promise as content for prevention programming. Using Emotional Labor Theory, we offer psychological services-based recommendations for future prevention programming and research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Gender identity assessment with trans individuals – findings of a systematic literature review of assessment instruments and ethical considerations

PurposeIn several Western legislations, trans individuals must frequently undergo some form of gender identity assessment, for example, to receive legal recognition of their gender or to access therapeutic interventions. Thus, a standardised and empirically supported assessment approach becomes necessary. The purpose of this paper is to critically reflect on the current international guidelines for assessments by the World Professional Association for Transgender Health, which will be compared to standards in secure forensic settings, illustrated by British prison policies.Design/methodology/approachFindings of a systematic literature review following preferred reporting items for systematic reviews and meta-analysis standards are presented, summarising the current state of research pertaining to gender identity assessment instruments. Studies were included, when they presented empirical details pertaining to assessment approaches and passed the quality appraisal, but were excluded when they did not use a trans sample or presented clinical assessments not linked to gender identity.FindingsA total of 21 included English articles, which mostly have been published in the USA in the past 20 years, propose ten different assessment approaches. Most of the studies support the use of the Minnesota Multiphasic Personality Inventory-2, the Bem Sex-Role Inventory, Body Image Scale for Transsexuals and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. The instruments are briefly summarised.Practical implicationsIt becomes apparent that this field is severely understudied and that there is no consensus regarding the best assessment approach. Hence, any recommendations are only preliminary and are contextualised with further ethical considerations and suggestions for future research.Originality/valueTo the best of the author’s knowledge, this is the first systematic literature review pertaining to the (semi-)structured assessment of gender identity.

'We try' - how nurses work with patient participation in forensic psychiatric care.

Patients in secure forensic psychiatric care have reduced autonomy because of the constraints imposed on them by compulsion laws. Thus, it is vital that nurses enable patient participation whenever possible. Patient participation, and it's clinical use in forensic psychiatric care, is an understudied field. To describe nurses' experiences of their work with patient participation in forensic psychiatric care. Managers at different secure forensic psychiatric institutions in the south of Sweden approved the study, and oral consent was retrieved from informants. Interviews guided by a semi-structured interview guide were conducted with nine nurses from five different forensic psychiatric institutions and analysed with content analysis. Nurses describe diverse understandings and abilities in an inflexible setting. This indicates that what participation is, and how to achieve it, is not the same for nurses as for patients. Moreover, patients have different abilities to participate, and the secure setting in itself is perceived as hindering participatory work. Still, participation is described as a crucial part of work that requires a caring relationship. Furthermore, nurses pronounce potentially excluding attitudes and strategies that may obstruct patient participation for all, and at the same time, they have a belief that improvement is possible. Compulsory forensic psychiatric care is a complex care context that requires constant efforts from nurses to balance patients' rights and needs with mandatory care. The very nature of this caring context appears to be a major obstacle when promoting patient participation. Nevertheless, nurses express that they do aim for patient participation, 'they try'. From a patient's perspective, trying is not sufficient and a need for improvement is evident. The results can be of clinical interest in similar secure forensic psychiatric nursing settings, and a point of departure in future development of care striving for increased patient participation for all.

Exploring multi-disciplinary team meetings on a personality-disorder ward within a forensic setting

Purpose The purpose of this paper is to understand how patients on a low security personality disorder ward experienced multi-disciplinary team (MDT) meetings, in order to suggest improvements that would benefit the patients and clinical teams. Design/methodology/approach The design was a case study where all patients on a low secure ward that specialised in personality disorders were approached to take part in the research. The study utilised non-participant observations of the MDT meeting (n=11), followed by individual interviews with the patients (n=10). Findings The data were subjected to a thematic analysis and this illuminated five themes relating to the patients’ experience of the MDT meetings namely, the importance of leave applications, the formality of the meetings, the opportunity to check on progress, decision-making and the importance of communication. Practical implications The findings suggest that small changes could be made to improve the patients’ experience of the MDT meeting. These included the provision of a less formal setting, ensuring a system where leave can be requested confidentially, greater transparency about the content of progress reports, and clearer communication between the MDT and the patient after the meeting. Originality/value There is limited research that has explored patients’ experiences of MDT meetings within secure forensic settings, and the use of non-participant observations of the MDT meeting followed by semi-structured interviews meant that the researcher and the patient had a shared experience that formed the basis of the later discussion.

Integrated substance use rehabilitation in a secure forensic facility

Purpose The purpose of this paper is to inform the development of an evidence-based and effective rehabilitation programme to address substance use disorders in a population of patients with severe mental illness and mental disorders detained in a secure forensic psychiatric facility. A clinical review identified a high prevalence of substance use disorders in the patient population at a secure forensic facility in Sydney, Australia with only a limited number of patients being assessed and offered interventions for substance use problems. Design/methodology/approach A literature review was undertaken specifically looking at articles between 2009 and 2017 that considered models of care or approaches to substance use rehabilitation in patients with co-morbid psychiatric disorders. Articles were considered based on their relevance to the purpose and the environment of a secure forensic facility. Findings The literature review emphasised the need for a cohesive model of care integrating substance use rehabilitation with mental health care. Comprehensive assessment and individualised approaches that incorporated patient choice and stages of change were considered essential components to any dual diagnosis rehabilitation programme. Practical implications The literature regarding rehabilitation approaches for those with severe mental illness and co-morbid substance use disorders was reasonably consistent with the models of care used in relation to criminal offenders and mental illness generally. Integrated and individualised rehabilitation approaches for dual diagnosis patients could play a significant role in forensic settings. Originality/value Limited robust evidence for substance use rehabilitation has been published. The authors consider the existing evidence base and the underlying theory behind substance use rehabilitation to propose a model for rehabilitation in secure forensic settings. This is the first known review of substance use rehabilitation involving mentally ill offenders with dual diagnoses in secure forensic settings. This paper is the original work of the authors.

Staff's perception of Patients’ affiliation and control in a Highly Secure Psychiatric Setting

Effective interactions between patients and staff have been associated with positive ward climate and therapeutic effects, but also pose a challenge in high secure forensic psychiatric settings. The goal of this study was to gain more insight into i) the characteristics that play a role in how staff members perceive the interpersonal style of patients, and ii) whether these perceptions are related to patients’ evaluation of ward climate and satisfaction with daily staff. Staff members (n = 69), rated the interpersonal style of 102 male patients. Satisfaction with daily staff and ward climate were rated by 45 patients. Results show that patient characteristics (primary diagnosis, patient age, disruptive behavior, recent problems with symptoms of major mental disorder and recent problems with treatment or supervision response) were related to how staff perceived the interpersonal style (i.e., affiliation and control) of patients. Furthermore, the level of affiliation was positively related to patients’ satisfaction with daily staff. Patients that were seen as more controlling by staff were less satisfied with the safety on their ward (as a factor of ward climate). The results indicate that perception of patients’ interpersonal style entails patient related information and can be relevant for staff to use in their work.

Agents and spectres: Life-space on a medium secure forensic psychiatric unit

Medium secure forensic psychiatric units are unique environments within the broader ‘post asylum’ landscape of mental health services. Length of stay is much greater, a recovery-focused care system is much more difficult to implement, and there is a paucity of suitable “step-down” services. The aim of this study was to examine how forensic psychiatric environments contribute to the shaping of recovery, by examining key features such as social interactions and agency. Here, we report on the findings from patients participating in a qualitative-visual study. This analysis forms part of larger study on staff and patient experiences of secure hospital space. In this paper, the analytical focus is directed towards two key elements of recovery - agency and relationality, using the concept of ‘topology’ and ‘life-space’, developed by the social psychologist Kurt Lewin. First, we explore how patients have relative freedom to move within institutional spaces, yet lack relational space. Secondly, we explore how life-space is expanded or compressed by the manner in which the patient's present life in hospital is connected or disconnected from their past or pending future. Finally, we discuss the implications of these findings for a recovery model within secure forensic settings, focused on personalisation and expanded life-space.

Staff perceptions of positive behavioural support in a secure forensic adult mental health setting

PurposeChallenging behaviour has been a concern across forensic services. Traditionally these have been managed reactively using medication, seclusion and restraint; however, there is growing evidence that these approaches are ineffective and counter-therapeutic. A number of reports have recommended the use of preventative approaches such as positive behavioural support (PBS). The purpose of this paper is to identify “how staff within a secure forensic mental health setting perceived the application of PBS?”Design/methodology/approachIn total, 11 multi-disciplinary staff were interviewed and thematic analysis was used to identify themes.FindingsFive themes were identified: “The Functions”, “Appraising a new Approach”, “Collaborative Challenges”, “Staff Variables” and “Organisational Issues”.Practical implicationsPBS enables staff to understand challenging or risky behaviour. It empowers patients via collaboration, although there can be some challenges to this. Services need to invest in training, support and leadership to ensure the model is embed and promote fidelity. Consideration needs to be given to how quality of life can be improved within the limits of a forensic setting.Originality/valueNo previous studies asking staff about their experiences of PBS within a forensic mental health context.

Development of forensic normative data for the WAIS-IV

PurposeThe Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV) (Wechsler, 2008) is a cognitive assessment that is often used in secure forensic settings, however it has not been normed on this population. The purpose of this paper is to develop forensic normative data.Design/methodology/approachPatient files in a high secure forensic hospital were reviewed in order to obtain completed WAIS-IV (Wechsler, 2008) assessments and scores from the five indexes (verbal comprehension, perceptual reasoning, working memory, processing speed and full scale intelligence quotient (FSIQ)). This included reviewing patient files from all directorates, including male mental health, male learning disability, male personality disorder and the women’s service, yielding a sample size of n=86.FindingsThe qualitative descriptors obtained across the hospital ranged between extremely low and superior. The learning disability service scored significantly lower than the mental health and personality disorder services in verbal comprehension index, perceptual reasoning index, working memory index and FSIQ, and significantly lower than the mental health, personality disorder and women’s services in processing speed index. Mean scores from this study were significantly lower in comparison to those from the UK validation study (Wechsler, 2008).Practical implicationsThe significant difference between scores from the current study and those from the UK validation study (Wechsler, 2008) highlights the need to have appropriate normative data for forensic populations. Clinicians should consider interventions that may serve to increase cognitive function, such as cognitive remediation therapy.Originality/valueWhilst several special group studies have previously been conducted, this study is the first to develop forensic normative data for the WAIS-IV (Wechsler, 2008). Whilst the sample size was relatively small with limited female participants, the data collated will enable clinicians working in forensic establishments to interpret their assessments in light of this information.

The impact of masculinity upon men with psychosis who reside in secure forensic settings

PurposeMasculinity is a core cognitive structure that plays a central role in organising attitudinal and behavioural processes. Yet there is limited research focussing upon the meaning of masculinity for men who have a past history of violent behaviour, who experience psychotic phenomena and reside in secure forensic settings. The paper aims to discuss these issues.Design/methodology/approachQ-methodology was used to elucidate the factors regarding how men who experience psychotic phenomena perceive their masculinity. Ten participants from a secure forensic setting performed a 49-statement Q-sort task.FindingsPrincipal component factor analysis with varimax rotation was performed on the ten completed Q-sorts which revealed a three-factor solution, accounting for 57 per cent of the variance in the data. The factors were interpreted and discussed under the following headings: “assured and asserting maverick”, “calm, confident, composed conformist” and “nurturing provider in the face of adversity”. This revealed that men with psychosis have different, predominantly pro-social explanatory frameworks for their representation of masculinity.Research limitations/implicationsThis study revealed that men with psychosis have different, predominantly pro-social explanatory frameworks for their representation of masculinity. However, the study was limited by its lack of longitudinal assessment and the inclusion of a greater number of participants may have enhanced the representativeness and generalisability of the findings.Practical implicationsTherapeutic discussions in respect of masculinity itself could provide men with the opportunity to develop newer, more adaptive conceptualisations of themselves, help them develop greater self-awareness and understanding of the sources of their presenting concerns, which in turn could enhance a provisional formulation of their difficulties. It would also be potentially valuable to understand how these patterns of masculinity map onto coping, recovery style and service engagement. Furthermore, services could also benefit from becoming more aware of hospitalisation being a shameful perhaps stigmatizing time for men with psychosis.Social implicationsIt may be useful for people working in healthcare settings to be aware of how the service users they support perceive their masculinity, so the existential and deeper needs of male patients are provided with enough consideration. This is an important point, as some individuals are often reluctant or neglect to enquire about individual’s psychotic experiences and gender identification.Originality/valueAlthough forensic psychiatric care is primarily populated by men who have committed violent acts, there is a limited research focussing upon the meaning of masculinity in this context. This is in spite of evidence which shows that maladaptive perceptions of masculinity can be reinforced during time spent residing in secure settings. The cultural constructs of masculinity and their respective impact upon the diagnosis, management and outcome of psychosis has also received little attention. Therefore, this research represents new and significant contributions to the field.

Compassion focussed working in secure forensic care

Purpose The purpose of this paper is to describe practices associated with compassion focussed therapy (CFT) in a secure forensic setting for men with a learning disability and personality disorder. The values of this model for both therapeutic work and the organisation of residential practices in a secure setting are considered. Design/methodology/approach The paper presents a conceptual discussion of the use of CFT with an offender population. Findings The paper describes the use of CFT as a framework for working with offenders with an intellectual disability and personality disorder. The paper discusses the organisation of service practices alongside more formal therapeutic interventions. Practical implications CFT offers a unique integrated model for working with offenders. The core CFT model invites staff teams to consider the safety seeking aspects of challenging behaviours and to understand these behaviours in the context of evolved threat processing mechanisms. The focus on emotional processing that is central to the model invites services to develop deep understanding of the functions of violence and other offending behaviours and to balance work in these areas alongside the development of capacities that offer individuals methods for effective emotional regulation. Originality/value The paper provides a unique discussion point for the organisation of forensic services for this population. The consideration of the wider social context of offender rehabilitation in terms of the residential settings, and the juxtaposition of this with formal treatments is rarely considered.

Clinician Perspectives of Inpatient Forensic Psychiatric Rehabilitation in a Low Secure Setting: A Qualitative Study

There is a dearth of research into what low secure forensic psychiatric rehabilitation means in Australia and internationally. The aim of this study was to understand clinician perspectives of forensic psychiatric rehabilitation in a low secure setting in Australia and offer insight into a model of care. A qualitative methodology was chosen with separate semi-structured interviews being conducted with staff members involved in decision-making for forensic psychiatric patients in a rehabilitation unit. Analysis of the interviews identified three domains that the questions related to: ‘defining and describing security’, ‘defining and describing low secure forensic psychiatric rehabilitation’ and ‘describing the role of staff and services in a low secure forensic psychiatric rehabilitation setting’. Where relevant, themes were abstracted from the questions that related to these domains. This study revealed that clinicians had a varied understanding of definitions for security but a similar understanding of what low secure forensic psychiatric rehabilitation means, what patients are suitable and the general goals of rehabilitation in this setting. Further research is needed on low secure rehabilitation and specific models of care. There is also a need to develop clear definitions for both security and rehabilitation in low secure forensic psychiatric settings.

Social cognition and paranoia in forensic inpatients with schizophrenia: A cross-sectional study

BackgroundPeople diagnosed with schizophrenia have difficulties in emotion recognition and theory of mind, and these may contribute to paranoia. The aim of this study was to determine whether this relationship is evident in patients residing in a secure forensic setting. MethodTwenty-seven male participants with a diagnosis of schizophrenia and a history of offending behaviour were assessed using The Awareness of Social Inference Test (TASIT), The Ambiguous Intentions Hostility Questionnaire (AIHQ) and The Green et al. Paranoid Thought Scales (G-PTS). Individuals were recruited from two medium secure and one high secure forensic hospital in Scotland. ResultsCorrelation, logistic and multiple regression analyses did not find that emotion recognition and theory of mind were associated with indices of paranoid thinking. ConclusionSocial cognition did not appear to be related to indices of paranoia in this forensic sample. Although participants reported low levels of paranoia overall, the results are consistent with recent conclusions that theory of mind impairments are not specifically linked to paranoia in people diagnosed with schizophrenia.

‘You need to meet with the psychologist before you can have any leave’: Reflections on ‘coercion’ in a secure forensic setting

‘You need to meet with the psychologist before you can have any leave’: Reflections on ‘coercion’ in a secure forensic setting

Mindfulness group for men in a low secure forensic setting: A pilot study

This article presents an evaluation of an eight week mindfulness group facilitated for men accessing a low secure inpatient service in the north of England. Service user feedback on the group is presented and recommendations for future practice are considered.