Secure Psychiatric Unit Research Articles

Institutional firesetting in a forensic inpatient population

ABSTRACT Institutional firesetting is a widespread and serious problem in custodial settings. However, there is very little research into the subject. This paper describes the characteristics and firesetting histories of 32 patients with histories of institutional firesetting in a secure psychiatric unit in the UK. Only six patients (18.8%) had a prior conviction for firesetting, while a further eight (25.0%) had a history of firesetting but no conviction). All institutional firesetting was carried out alone, most commonly in a cell or bedroom. Institutional firesetting was significantly more common among patients with a diagnosis of personality disorder than among those with a diagnosis of mental illness. The results are consistent with the M-TTAF trajectories model of firesetting. Different patterns of firesetting may emerge in institutional settings because firesetting may be one of an extremely limited repertoire of problem solving strategies and may be inadvertently reinforced in these settings. These results suggest that there may be a subgroup of institutional firesetters with no previous history of firesetting and this is a group that merits more detailed study.

Voluntary and coercive covert trading behaviour on low and medium secure psychiatric units: a cross-sectional study

ABSTRACT Little is known about covert trading behaviour in secure hospital settings. This study evaluated the nature, prevalence, and frequency of covert voluntary trading behaviour (VTB) and of coercive trading behaviour (CTB) between patients in secure psychiatric units. Ninety-six eligible patients in 18 low or medium secure wards across South London anonymously completed a questionnaire exploring their experiences of covert trading behaviour (including exchanging, lending, borrowing, or gifting personal property, money, or services) during their current hospital admission. About 70.2% reported engaging in some form of unauthorised VTB (38.3% ≥5 different behaviours). VTB was more commonly reported by male (74.7%) than female (36.3%) participants (odds ratio (OR) = 4.93, 95% confidence intervals (CI) = 1.28,19.05, p = 0.021). Engagement in any CTB behaviour was reported by fewer patients (31.9%). Participants were significantly more likely to report themselves as victims of coercive behaviours (8.6%–14.0% across different behaviours) rather than instigators (1.1%–5.5% across behaviours). Involvement in CTB was more common in patients reporting VTB (39.4%) compared to those not involved in VTB (14.3%; OR = 3.90, CI = 1.21,12.54). Covert patient trading appears commonplace in secure psychiatric inpatient settings and VTB participation may be linked with CTB engagement. Hospital policies to better monitor and regulate patient trading may help to reduce the incidence of CTB.

Sensory approaches in psychiatric units: Patterns and influences of use in one Australian health region.

Australian guidelines and policies recommend the use of sensory approaches in mental health care. Nevertheless, many Australian psychiatric units report difficulty sustaining these approaches. To inform efforts to close the gap between recommendations and practice, the aim of this study was to understand the patterns of use of sensory approaches and what demographic and clinical factors influence their use, across one health region in Queensland, Australia. Using a cross-sectional survey design, a custom-designed questionnaire was distributed via email and in paper form to health professionals and peer support workers working in acute, secure, and community care psychiatric units across one health region. Information on demographics and the use of various sensory interventions was gathered utilising both open-ended and Likert scale questions. Useable questionnaires were collected from 183 participants from various disciplines (77% nursing). The majority reported using sensory approaches with a limited number of consumers, and almost 9% never used the approach. Activity-based sensory interventions and sensory equipment were most often used, whereas sensory assessments, sensory plans, and sensory groups were least used. Sensory interventions were mainly used to reduce consumer anxiety and agitation and to assist with emotional regulation. Factors positively correlated with frequency of use for all interventions were discipline (occupational therapy); working in an acute inpatient unit; and training in sensory approaches. Age was negatively correlated with frequency of use only for weighted modalities. This study revealed that sensory approaches were used by most staff though with a limited proportion of consumers in psychiatric units in one large metropolitan health service. It provides insights into the factors influencing frequency of use, highlighting the importance of training in sensory approaches and access to occupational therapists. With this knowledge, we can work towards closing the gap between recommendations and the practice of sensory approaches.

A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria.

To identify the most relevant clinical and video-polysomnographic characteristics of patients with sleep-related dissociative disorders (SRDDs) and to propose a framework for new diagnostic criteria. We searched potential SRDD cases from the scientific literature and from a database of patients referred for clinical and video-polysomnographic assessment in a single sleep disorders center for disruptive nocturnal behaviors (n = 731). The most relevant clinical and neurophysiological characteristics of the cases were extracted and a descriptive analysis was performed. Twenty-six SRDD cases (8 new and 18 previously published cases) were reviewed. Almost all cases of SRDDs occurred in a context of past traumatic events or abuse and were associated with at least 1 comorbid psychiatric disorder. We highlighted 4 relevant clinical characteristics of SRDD useful for the differential diagnosis with parasomnias: episodes of long duration of more than 1 hour (90.9%), self-inflicted injuries (83.3%), occurrence while awake close to bedtime (35.7%), and the presence of daytime dissociative symptoms (72.7%). The video-polysomnography documented typical episodes of SRDD with prolonged wakefulness before, during, and after the event in 11/26 cases. New diagnostic criteria for SRDD were proposed, with 3 levels of certainty for the diagnosis based on clinical, video-polysomnographic, and homemade video findings. More than 30 years after its formal identification, SRDD is not currently recognized as an official diagnostic entity. We better delineate the clinical and neurophysiological features of SRDD and propose a framework for its reinstatement in the next revisions of the sleep and psychiatric disorders classifications. Lopez R, Lefevre L, Barateau L, Micoulaud-Franchi J-A, Dauvilliers Y, Schenck CH. A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria. J Clin Sleep Med. 2022;18(2):563-573.

Clinical and criminal profile of internet offenders with ASD

Purpose Autism-specific characteristics have been associated with internet criminal activities. Internet and non-internet offenders differ on a series of demographic, psychological and offending variables. However, the clinical and criminal presentation of individuals with autism spectrum disorder (ASD) in forensic secure care settings has been underexplored. This paper aims to explore the profiles of internet offenders with ASD admitted to a secure psychiatric unit. Design/methodology/approach This study provides the results of a service evaluation of individuals with ASD. The demographic, clinical and criminal characteristics of a small sample of internet offenders with ASD admitted to secure care are described and discussed. Findings Internet offenders present in secure care with high rates of comorbid disorders, histories of violence and traumatic experiences, mood disorders and difficulties with relationships. Of the 24 internet offenders discussed, 18 of them committed an offence of a sexual nature involving children. Originality/value This paper highlights the potential risks for individuals with ASD in using the internet and the possible difficulties associated with detecting this because of rapid advancements in technology.

Absconsion in forensic psychiatric services: a systematic review of literature.

While serious concerns are often raised when patients abscond or leave unauthorized from psychiatric services, there is limited knowledge about absconsion in forensic psychiatric services. Following the preferred reporting items for systematic reviews and meta-analyses guideline, we searched Medline/PubMed, PsycINFO, EMBASE, CINAHL, Scopus, and Web of Science through May 2020 for eligible reports on absconsion in forensic patients with no language limits. The search string combined terms for absconsion, forensic patients, and psychiatry in various permutations. This was supplemented by snowball searching for additional studies. Of the 565 articles screened, 25 eligible studies, including two interventional, seven cross-sectional, and 16 case-controlled studies spanning five decades were included. Absconsion and re-absconsion rates ranged from 0.2% to 54.4% and 15% to 71%, respectively, albeit higher rates trended with less secure psychiatric units. Previous absconsion, aggression, substance use, high Historical Clinical Risk Management-20 score, anti-sociality, psychiatric symptoms, sexual offending, and poor treatment adherence were the factors reported with a degree of predictive value for absconsion. However, the construct of absconsion was heterogeneous in the included studies and the quality of evidence on the predictors of absconsion was limited. Serious risky behaviors including re-offending, violence, self-harm, suicide, rape, and manslaughter were perpetrated by patients during unauthorized leave. Nevertheless, the rates of re-offending were generally low in the included studies (highest recidivism rate=0.11). There is need for standardized assessment and documentation of absconsion to improve risk analysis and management. Furthermore, it is necessary to develop a structured guideline for defining absconsion, and to create a protocol that operationalizes all absconsion-related behaviors/events to promote reliable assessment and comparative analysis in future studies.

A psychoanalytic contribution to the understanding of criminal tendencies

The present work provides a novel contribution to the psychoanalytic literature on criminal tendencies and is based on an experience of group supervision with the staff of professionals in an Italian Secure Psychiatric Unit. With the support of a single case from that institution, the case of Mary, and two more clinical illustrations, new insights on the criminal act will be presented and discussed according to three main themes: a) the failure of containment; b) the antisocial act as a concrete attempt to represent internal conflicts; c) the violent internal aspect as the place where the patient’s psychic vitality resides. The work concludes by showing how the care team, within this kind of institution, can promote the patients’ psychic development on each of the following three themes: a) acting as a transformative container; b) being capable of restoring a symbolic and representational dimension to violent and antisocial acts; c) being capable of restoring the aspect of the psychic vitality of violent and antisocial acts to promote the passage towards the differentiation between +psychic vitality and -psychic vitality.

The man who confessed he was a serial killer

In December 1990, two men carried out a bank robbery in a small town in Sweden. It went farcically wrong. The men wore balaclavas and Santa Claus masks, and attempted...

Coping, Mindfulness, Stress, and Burnout among Forensic Health Care Professionals

ABSTRACTAlthough working within forensic services can often prove emotionally challenging and stressful, there has been a surprising lack of research into potential interventions aimed at addressing stress and burnout experienced by forensic health care professionals (FHCPs). This study investigated the role of coping and dispositional mindfulness on stress and burnout among FHCPs employed within secure hospitals. One hundred and fifty-one FHCPs were recruited from five different low and medium secure hospitals (secure psychiatric units) in Wales. A postal research pack was used to collect background information and measures of coping, dispositional mindfulness, stress, and burnout. The study found that FHCPs reported elevated levels of stress and moderate levels of emotional exhaustion and depersonalization but retained a positive sense of personal accomplishment. Higher mindfulness skills were found to be significantly associated with lower levels of maladaptive coping, stress, and burnout. Higher levels of maladaptive coping significantly predicted elevated levels of stress and emotional exhaustion and lower levels of personal accomplishment. In relation to mindfulness, higher levels of acting with awareness significantly predicted lower levels of emotional exhaustion and depersonalization. The results appeared to support the commonly held assertion that forensic services can be stressful and emotionally challenging working environments, which can cause FHCPs to experience elevated levels of burnout and stress. Higher levels of dispositional mindfulness were significantly associated with lower maladaptive coping, stress, and burnout levels, therefore mindfulness based interventions could prove to be viable strategies to help support FHCPs. The results also suggested that higher levels of acting with awareness may help prevent FHCPs from experiencing emotional exhaustion and depersonalization.

Characteristics and personality profiles of first 100 patients admitted to a secure forensic adolescent hospital

ABSTRACTBluebird House is a mixed-gender adolescent medium-secure forensic unit. There is a paucity of data available about this unique patient group. We aimed to explore the demographic, clinical and personality characteristics of the first 100 patients admitted to a mixed-gender adolescent medium-secure forensic unit. We used a retrospective cross-sectional study of the first 100 consecutive patients admitted to Bluebird House. Demographic and clinical data were collected from the medical notes including the Millon Adolescent Clinical Inventory. The first 100 young people admitted to an adolescent medium-secure unit have had very high incident rates, particularly amongst the females. Incident rate was correlated with a history of sexual assault in female patients. The males were more likely to have been referred from custody and more likely to have a diagnosis of psychosis or autism. We describe similarities and differences to the first 100 admissions admitted to the first secure psychiatric unit for adolescents in Manchester over 20 years ago.

How secure are the secure psychiatric units in New South Wales?

To evaluate the therapeutic security characteristics of the secure forensic mental health inpatient units in New South Wales, Australia. This study evaluated all eight secure inpatient units in New South Wales using a validated tool, the Security Needs Assessment Profile. A pattern of decreasing therapeutic security across the secure units was found, consistent with their intended security levels, from high security through to open security. However, important inconsistencies across and between levels of security were highlighted. This study clarifies the therapeutic security structure of the New South Wales forensic mental health service, which is an essential first step in service development and reform.

Mental health law in Cyprus.

The current Law for Psychiatric Care in the Republic of Cyprus was enacted in 1997 with amendments made in 2003 and 2007. The mental health law makes provision for the development and function of Psychiatric Centres for the care of the mentally ill. In contrast to the old Mental Health Law there is a major shift from a custodial approach to community care. Compulsory admissions under the Act, which require a Court Order, are made to a designated secure psychiatric in-patient unit. The protection of patients' human rights is at the core of the Act. The Mental Health Commission, a Supervisory Committee and designated body for the Protection of the Rights of the Mentally Ill, assists in the correct implementation of the Mental Health Law. The Commission has a primarily advisory role but it is actively involved in monitoring the implementation of the Mental Health Law.

Staff members’ evaluation of inpatients’ motivation for aggression – the roles of staff restrictions and aggression severity

Improved understanding of inpatient aggression can come from systematic assessment of motivation for aggressive incidents. This study investigates staff members’ evaluation of motivation for aggressive incidents, and how such evaluations are influenced by staff restrictions and aggression severity. Staff reports of aggressive incidents in a secure psychiatric unit were collected in clinical practice over a ten-year period (2006–2015). Motivation for aggression was assessed with the Aggressive Incident Motivation Evaluation Scale, measuring irritable, instrumental, and defensive dimensions. Information about staff restrictions was collected with the Staff Observation Aggression Scale – Revised, and severity was rated with the Visual Analog Scale. Multilevel analyses of 2649 aggressive incidents, committed by 67 inpatients, revealed greater variation in aggression motivation across incidents than between individual patients. Staff restrictions preceding the aggressive incident and rating of severity were positively related to staffs’ evaluation of motivation for aggression, but their impacts differed across motivational dimensions. Staff reports of motivation provide important additional information beyond current standard report forms. Systematically evaluating motivation is essential to risk management, and may contribute to develop more fine-tuned interventions for preventing and managing aggression in inpatient settings.

New Hampshire Hospital ‘Stays Safe’ Through Violence-Reduction Program

New Hampshire Hospital ‘Stays Safe’ Through Violence-Reduction Program

Psychopathy in women: Prediction of criminality and violence in UK and USA psychiatric patients resident in the community

Psychopathy is an important clinical construct often used in the assessment and management of psychiatric patients and offenders. This, in part, is due to the strong association between psychopathy, crime, and particularly violent crime. However, there are few studies of these associations in women. These relationships were examined using information from two large databases. The Partnerships in Care database contains data from a sample of forensic psychiatric patients (154 women and 777 men) in the UK that were discharged from secure psychiatric units. Follow-up was via official conviction data within the next 2 years. The MacArthur study examined violence and aggression in a sample of civil psychiatric patients (367 women and 496 men) in the USA following discharge from an acute psychiatric hospital. Follow-up was via a mixture of self-report, informant report and official records. Psychopathy in both samples was measured via the PCL:SV prior to discharge. Psychopathy was a good predictor of target events for the women in both samples and for all time intervals used. No significant gender differences in the PCL:SV’s predictive efficacy were found. The results provide a strong evidence-base for the use of psychopathy in women when considering future community behaviour and reoffending.

Patient and staff experience of a ward-based risk management system

IntroductionEnsuring safety in secure psychiatric units for women is dependent on a clear rationale and structure underpinning risk management. The reinforcement of positive behaviour needs to be balanced by contingencies to prevent ineffective behaviours being reinforced. The use of a Risk Stage System is based on the notion of equality of contingency for similar risk behaviour.MethodSecure ward staff and women patients completed service structured interviews to determine their view of the Risk Stage System in terms of its perceived value in risk management and recovery.ResultsStaff and patients with previous experience of the Risk Status System positively evaluated it. Patients in medium security currently subject to the system were divided on the issue of whether it helped in focussing on recovery and keeping patients and staff safe.Discussion & ConclusionsThe division between staff and patients’ opinion indicates the need to thoroughly engage patients in the risk management process, to arrive at a shared understanding of boundaries and to consistently implement agreed procedures.

The impact of treatment on hostile-dominance in forensic psychiatric inpatients: relationships between change in hostile-dominance and recidivism following release from custody

This study explored the impact of psychiatric and psychological treatment on hostile-dominance in 51 offenders with personality disorder in a secure psychiatric unit. Hostile-dominance was assessed at intake and repeated at six monthly intervals. In 28 of the participants with reassessment of hostile-dominance, who were subsequently discharged into the community, the association between reoffending (Grave and Any) and change in hostile-dominance (measured by subtracting the final hostile-dominance score from the initial score), psychopathic traits, Antisocial Personality Disorder (ASPD) and treatment completion/non-completion was examined. Results revealed that patients who completed treatment evidenced a reduction in hostile-dominance, whereas patients who did not complete treatment worsened. Logistic regression analyses showed that reduced hostile-dominance, psychopathy and ASPD predicted reoffending (Any). Treatment completion and Psychopathy Checklist Factor 1 scores predicted Grave reoffending. Findings are supportive of the potential for the level of hostile-dominance to be reduced through completion of appropriate treatment; such changes are important to reductions in reoffending.

Detecting offence paralleling behaviours in a medium secure psychiatric unit

Purpose Offence paralleling behaviour (OPB) is a relatively new concept that emphasizes the assessment and modification of behavioural patterns that parallel criminal offending. Extant empirical research into OPB has typically focussed on the similarity between aggressive behaviours observed in custody and violent index offences perpetrated in the community; the results of these studies have been inconsistent, with the degree of similarity varying within subjects and across studies; (Daffern, Howells, Stacey, Hogue, & Mooney, 2008; Daffern, Howells, Mannion, & Tonkin, 2009). The aim of this study was to establish the level of similarity between OPB predictions and actual in-patient aggressive behaviours. Method This prospective pilot study used a novel practice algorithm (Jones, 2010a) to develop a reference formulation from which OPBs and Pro-social alternate behaviours (PABs), the pro-social variants of OPBs, were predicted. Participants were five mentally disordered offenders resident in a UK medium secure psychiatric unit. Following generation of a reference formulation and OPB and PAB predictions the participants were monitored for 6 months. The degree of similarity between predicted and actual OPBs and PABs was calculated using Jaccard's coefficient. Results Results indicated considerable similarity between matched (pairing predictions and their corresponding actual behaviours) OPBs, which were also more similar than random pairs (pairing randomly selected predictions and aggressive behaviours). Conclusion This study revealed the existence of OPB in mentally disordered offenders and has provided the first test of a novel practice algorithm, revealing its potential to guide OPB formulations.

A description and evaluation of a challenging behaviour workshop

BackgroundEnsuring good quality staff and patient relationships are key goals of long-stay inpatient services. It is therefore essential that staff have a good understanding of patients' needs and how to work with the challenges that can present in these environments.AimsWe evaluated the feasibility and acceptability of a workshop to help psychiatric staff with challenging behaviours.DesignWe used a quasi experimental design with assessments carried out at baseline and post intervention. We provided the training to staff on one low secure psychiatric unit and recorded the uptake of outcome assessments and the workshop itself. We assessed staff–patient relationships, burnout and ward atmosphere and staff also completed satisfaction questionnaires.ResultsSixty-six percent of staff (n = 25) who were eligible to participate in the project completed initial outcome measures, but only 42% (n = 16) attended the workshop and only 34% (n = 13) completed follow-up measures. The workshop had no predicted effects on any of the outcomes assessed, but staff satisfaction with the training was generally positive.ConclusionsBuilding up positive relationships with staff, addressing negative expectations and seeking support from all levels of management are essential in terms of reducing barriers to training in psychiatric settings.

‘Real Relationships’: Sociable Interaction, Material Culture and Imprisonment in a Secure Psychiatric Unit

Research into the character of social relationships in psychiatric inpatient facilities has focused on face-to-face interaction between individuals and within groups in the communal areas of wards. Using theories developed in material culture and media studies, this article argues that patients' relationships to goods, namely, photographs, cards and gifts from family or friends, televisions and radios, are important mediators and constituents of sociability. In an ethnographic study of a medium-secure psychiatric unit, I show how these goods are put to use in private space in ways that reflect and mitigate the constraints of incarceration and stigmatization. The data were derived from 3 months of participant observation on a male and a female ward at a unit in the south of England, including a series of anthropological interviews with 19 patients. This article highlights two important findings. First, potentially isolating activities are perceived by patients as sociable, in that watching television and looking at photographs in their room helps to counter feelings of loneliness and isolation. Second, potentially sociable activities, exchanging goods or watching the communal television, are often practiced in such a way as to maintain distance between patients in acknowledgment of the constrained and volatile nature of these relationships. This suggests that patients aspire to retain a sense of the artificiality of their situation, preferring to confine their notion of 'real' relationships to those that exist outside the institution.