Secure Unit Research Articles

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: de-escalation and rapid tranquillisation

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Tackling obesity in mental health secure units: a mixed method synthesis of available evidence.

The prevalence and incidence of obesity are high in people with severe mental illness (SMI). In England, around 6000 people with SMI access care from secure mental health units. There is currently no specific guidance on how to reduce the risk of obesity-related morbidity and mortality in this population. To identify international evidence that addresses the issue of obesity in mental health secure units. A mixed method review of evidence (published 2000-2015) was carried out to assess obesity prevalence, intervention and policy change, as well as barriers to change. Evidence from 22 mainly small, non-comparator studies (reported in 21 papers) using a range of methods was reviewed. Dietary, physical activity and cultural interventions being implemented within secure units to address the problem of obesity showed some promising outcomes for physical health and health education. These were facilitated by adequate organisational resources, staff training and motivated staff. Holistic interventions that included a social and/or competitive element were more likely to be taken up. Involving patients in decision-making mediated the tension between facilitating behaviour change and imposing control. Barriers to successful outcomes included patient movement in and out of units, severity of mental health condition and resistance to change by patients and staff. Despite the promising outcomes reported, further assessment is needed of the feasibility, acceptability and effectiveness of interventions and policies targeting the obesogenic environment, using robust research methods. None.

Restriction of Liberties under the Ontario Review Board after (Re) Campbell

In Canada, Criminal Code Review Boards are established under Part XX.1 of the Criminal Code. The role of these independent tribunals is to make and review dispositions and decisions concerning persons found Not Criminally Responsible on Account of Mental Disorder or Unfit to Stand Trial. Under Part XX.1, there are certain provisions to protect the liberty interests of accused persons who remain under the authority of a provincial or territorial review board. These provisions trigger mandatory hearings before the Review Board. In (Re) Campbell, counsel for the accused argued before the Board that a transfer from one secure unit to a more secure unit required notice to the Board of a restriction of liberty and that the delay in notification resulted in a s. 7 Charter breach and that a s. 24(1) remedy was due. The Court of Appeal dismissed the appeal, confirming the Board’s decision that there was insufficient evidence regarding the accused’s liberty norm before the transfer and her liberty status after it to conclude that notice to the Board was required. Furthermore, the Court ruled that the transfer was the least onerous and least restrictive measure in the circumstances. The Campbell decision introduced an enhanced interpretation of the “significantly increasing the restrictions on the liberty of the accused” test by adopting a contextual approach which takes into consideration the accused’s liberty status before and after the decision to restrict the accused. Once a restriction is deemed to reach that threshold, the Board must determine whether the hospital’s measures were the least onerous and least restrictive in the circumstances. The Campbell decision will undoubtedly impact the way hospitals and review boards view restrictions of liberty, giving way to the potential for an increasing number of Chartercases argued on the grounds of alleged s. 7 violations.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation.

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Continuing clozapine treatment after a diagnosis of cardiomyopathy.

A patient in a medium secure psychiatric unit with a 19-year history of treatment-resistant schizophrenia and violence whose mental illness only responded to clozapine, was noted to have a sustained tachycardia. Echocardiography revealed mild biventricular cardiomyopathy. The patient was not significantly affected by this. Initial recommendation from Cardiology was to consider discontinuation of clozapine. It was decided, however, that the risk of worsening psychosis and resultant violence outweighed the risk of the patient's relatively mild cardiomyopathy. The patient was commenced on ramipril, and later bisoprolol. The patient no longer requires treatment in a medium secure unit and has remained on clozapine with follow-up from cardiology.

Restraint in mental health settings: is it time to declare a position?

The emergence of a drive to reduce restrictive interventions has been accompanied particularly in the UK by a debate focussing on restraint positions. Any restraint intervention delivered poorly can potentially lead to serious negative outcomes. More research is required to reliably state the risk attached to a particular position in a particular clinical circumstance.Declaration of interestF.S. is a consultant psychiatrist in Psychiatric Intensive Care at the Maudsley Hospital, London. He is on the Executive Committee of the National Association of Psychiatric Intensive Care and Low Secure Units, and was a member of the National Institute for Health and Care Excellence Guideline Development Group for the Short-Term Management of Aggression and Violence (2015). J.P. is a senior lecturer at the Faculty of Health and Life Sciences, Coventry University. E.B. is a consultant and expert witness in violence reduction and the use of physical interventions, independent expert to the High Secure Hospitals Violence Reduction Manual Steering Group and a member of the College of Policing Guideline Committee Steering Group and Mental Health Restraint Expert Reference Group. B.P. is the clinical director for Crisis and Aggression Limitation and Management (CALM) Training and formerly a senior lecturer for the Faculty of Health, University of Stirling. He is a nurse and psychotherapist and presently chairs the European Network for Training in the Management of Aggression. A.O'B. is a consultant psychiatrist, the Director of Educational Programmes for the National Association of Psychiatric Intensive Care and Low Secure Units, and the Dean for Students at St George's University of London.

‘Behind This Wall’ – Experiences of Seclusion on Locked Wards for Women

<p class="p1"><strong>Aim: </strong>To more fully understand the experiences of seclusion in a learning disability service for women. <p class="p2"><strong>Background: </strong>This paper reports on one of the analytical themes, seclusion, from an ethnographic study exploring the lives of learning disabled women on locked wards. <p class="p2"><strong>Method: </strong>Participant observation was used on three locked wards for women in a learning disability secure (forensic) unit in the United Kingdom. Themes from the analysis of field-notes were used to construct an interview schedule. Sixteen detained women and ten staff participated in interviews. <p class="p2"><strong>Results: </strong>The thematic analysis produced four areas of relevance: the seclusion room environment, reasons for using seclusion, termination of seclusion and alternatives to seclusion. <p class="p2"><strong>Conclusion: </strong>Detained women’s descriptions of seclusion portrayed a bewildering, distressing experience which violated their privacy. Alternative practices such as providing a space for anger and resolve, and time for discussion with staff were identified.

Violent offender treatment in a medium secure unit

PurposeThe purpose of this paper is to conduct a preliminary evaluation of a Violent Offender Treatment Program (VOTP) adapted for use in a medium secure unit (MSU). The patient population is adult male mentally disordered offenders.Design/methodology/approachPatient outcomes are explored using the Reliable Change Index and Clinical Significance Criterion. Outcomes are assessed using VOTP facilitators violence risk assessment (VRS), multi-disciplinary team violence risk assessment (HCR-20 and GAS-V), and patient self-report using two measures (FAVT and STAXI-2).FindingsThere was evidence of improved outcomes for some participants in some areas related to risk of violence.Research limitations/implicationsConsideration is given to using varied risk assessments to evaluate outcomes of an adapted VOTP for a MSU.Originality/valueThere is limited development and evaluation of psychological treatment programmes that aim to reduce risk of violence for male offenders within MSUs. Outcomes of this evaluation could influence treatment delivery and evaluation in other services.

The Firesetter's Search for "A Place Called Home"

Homes can become prisons, and prisons can become homes; both nurturing of the self, but also its violation. Houses in forensic sandplay imply issues of safety, security and containment, institutionalization and incarceration, reparation and resettlement, building, and hiding that is pertinent to the person, the psychotherapeutic experience and a complex relationship between secure settings and the psyche. Firesetting, a symbolic attack against "home" and property is often a response to conflict or crisis, expresses a desire, wish, or need, is influenced by learning disabilities, and can be a "cry for help" for those who have been neglected, traumatized, or abused, and when verbal language has been impossible. Sandplay images of two men in a low secure unit, who underwent firesetting treatment, provide glimpses of an internal world that seeks to repair inner damage, and where ruins express psychological homelessness; offering a return to natural shelter and activating a descent.

A Literature Review of Individual Placement and Support (IPS) for Forensic Patients and Implications for Future Research

The positive correlation between work and health is widely acknowledged and evidenced; and a strong predictor for successful community integration for forensic patients. Conversely, a lack of vocational opportunities progressively damages health, and potentially leads to disability, exasperation of mental illness and decreased life expectancy [1]. A review and literature search was undertaken to ascertain how vocational rehabilitation, specifically the individual placement and support model (IPS), within forensic settings can assist those transitioning from secure units to community living. Methods: A literature search carried out between January-March 2018 comprised of literature a) published post-2008, b) in English, c) focused on forensic settings and/or forensic patients, and d) peer-reviewed literature from academic journals. Excluded literature included: unpublished results, such as protocols, supplements, dissertations, and poster presentations; primary research was prioritised over opinion pieces or secondary reviews. Following the Department for Work and Pensions (DWP) recommendations for improved employment support for those with mental health illness, legislation concerning greater work opportunities was successively introduced. Therefore, literature published post-2008 allowed for Government whitepapers [2] based upon these recommendations to be incorporated. In addition, it also reflects pertinent developments in the field of occupational therapy, following [3] review, which criticised current forensic research as weak, lacking relevancy and methodological rigour. Conclusion: IPS research has primarily utilised quantitative data, measuring job tenure and risk-reduction, rather than depth of experience of patients, which could greatly improve occupational therapy practice and service delivery. IPS’ efficacy has been recommended within forensic institutions, yet little research exists for IPS’ impact within community settings.

Unit manager perspectives of a trauma-specific programme across Scotland’s secure estate

Purpose The purpose of this paper is to assess unit manager perspectives on the introduction of a group-based trauma-specific programme delivered across Scotland’s secure estate. As this was the first time such an estate-wide initiative had occurred, it was important to identify the benefits/challenges at a strategic level. Design/methodology/approach An exploratory qualitative case study was utilised involving semi-structured interviews with five senior unit managers in three secure units to discover their perceptions of the benefits and challenges of implementing Teaching Recovery Techniques (TRT). A quasi-qualitative analysis was used to quantify and give meaning to manager responses. Inter-rater reliability of analysis was assessed. Findings Unit managers perceived gains in trauma-informed knowledge for themselves, and knowledge and skills gains for programme workers, care staff and adolescents. Challenges involved: managing a shift in paradigm to include a trauma-specific programme; the limiting context of competitive tendering; short duration placements; and the need for psychoeducation for staff, parents and agencies. Research limitations/implications Large sample sizes are likely to identify further issues for unit managers. Manager perceptions need directly compared with staff and adolescent perceptions and included in randomised control trials of trauma-specific programmes. Practical implications Managers perceived that TRT needed to be delivered within trauma-informed organisations and identified the need for manager training in traumatisation, trauma recovery and organisational implications to guide strategic planning. Managers emphasised the need for psychoeducation for families, staff and agencies. Originality/value The current study is the first in Scotland to explore unit manager experience of introducing a trauma-specific programme across the secure estate.

Economic modelling of telehealth substitution of face-to-face specialist outpatient consultations for Queensland correctional facilities.

Objective The provision of healthcare services to inmates in correctional facilities is costly and resource-intensive. This study aimed to estimate the costs of transporting prisoners from 11 Queensland correctional facilities to the Princess Alexandra Hospital Secure Unit (PAHSU) in Brisbane for non-urgent specialist outpatient consultations and identify the cost consequences that would result from the substitution of face-to-face visits with telehealth consultations. Methods A 12-month retrospective review of patient activity at the PAHSU was conducted to obtain the number of transfers per correctional facility. The total cost of transfers was calculated with estimates for transport vehicle costs and correctional staff escort wages, per diem and accommodation costs. A cost model was developed to estimate the potential cost savings from substituting face-to-face consultations with telehealth consultations. A sensitivity analysis on the cost variables was conducted. Costs are reported from a government funding perspective and presented in 2016 Australian dollars (A$). Results There were 3539 inmate appointments from July 2015 to June 2016 at the PAHSU, primarily for imaging, general practice, and orthopaedics. Telehealth may result in cost savings from negligible to A$969731, depending on the proportion, and travel distance, of face-to-face consultations substituted by telehealth. Wages of correctional staff were found to be the most sensitive variable. Conclusions Under the modelled conditions, telehealth may reduce the cost of providing specialist outpatient consultations to prisoners in Queensland correctional facilities. Telehealth may improve the timeliness of services to a traditionally underserved population. What is known about the topic? Specialist medical services are located in only a few metropolitan centres across Australia, which requires some populations to travel long distances to attend appointments. Some face-to-face specialist outpatient consultations can be substituted by telehealth. What does this paper add? Prisoners from correctional facilities represent one specific population that requires complex travel arrangements for specialist medical appointments. Transportation of prisoners for specialist health appointments represents a substantial cost to the government. This paper quantifies the annual cost in Queensland for transporting prisoners, taking into account fuel and vehicle costs, staff wages, per diem rates, and accommodation. In addition, it quantifies the costs of substituting face-to-face consultations with telehealth consultations. What are the implications for practitioners? This research encourages practitioners to consider using telehealth services for prisoners, as well providing an argument for tertiary centres to include telehealth as a model of care for this population. Telehealth can result in major cost savings and state and federal governments should consider implementation especially in Australia where correctional facilities and specialist services are separated by great geographic distances.

Nurses’ views on reflective practice sessions in a medium secure unit

Aim Reflective practice is essential in the development of autonomous, critical and advanced practitioners, and can positively affect nurses at all levels. This study aimed to evaluate nurses’ experiences of participating in reflective practice sessions in a medium secure mental health service.Method Data were gathered over four months in 2013, through semi-structured interviews with eight nurse participants.Results Analysis revealed four themes – nursing growth, unsafe terrain, unmet needs, and a sense of direction and improved practice, which comprised both positive and negative elements.Conclusion To the best of the authors’ knowledge, this study is the first of its kind and contributes to the evidence base on reflective practice. Reflective sessions, although useful, are not always used effectively because of nurses’ concerns about psychological safety in the group and because of lack of staff. Better education about the aims, objectives and nature of reflective practice might improve nurses’ engagement.

Clinical psychologists’ perceptions of barriers and facilitators to engaging service users in index offence assessment and formulation within a medium secure unit

Index offence assessment and formulation (IOAF) helps service users (SU) in secure units to make sense of their index offence, provides detailed understanding of risk and contributes to treatment planning and discharge decisions. Clinical psychologists’ perceptions of barriers and facilitators to engaging SUs in IOAF within the men’s and women’s services of one medium secure unit were explored through focus groups. Thematic analysis identified two relevant domains: person-specific factors and the organisational context. Person-specific barriers included challenges in working with fragmented narratives, conflicting motivations to engage, SU defences and distorted perceptions of clinical psychologists’ roles. Giving clarity and choice to SUs facilitated engagement with the work. Regarding the organisational context, clinical psychologists within both services identified the importance of having adequate resources and care-team support to complete this work. Findings highlight the importance of developing an evidence-based framework for IOAF to be embedded within clear ‘risk’ care pathways through secure services.

“‘Call Security’: Locks, Risk, Privacy and Autonomy in Long-term Residential Care”

Locked doors and secure units are often used as a solution in long-term residential care (LTRC) for residents with moderate to severe dementia who are at risk for wandering and potentially harming themselves or others. This practice creates important quality of life implications for residents as well as for employees. In this paper we explore broader assumptions, connotations and possibilities of LTRC built environments by comparing and contrasting the use of and philosophies regarding the locking of doors and entire units in facilities that maintain this practice to those that have open doors, open units and other accessible physical spaces. This sub-study is part of a larger international, interdisciplinary study that uses rapid site-switching ethnography within a feminist political economy framework to investigate promising practices in LTRC. Field observations and interviews with management, health providers, support staff, informal care providers, union representatives, residents and family members were conducted in 27 sites, 10 of which we elected to include for the purpose of this paper, located in Nova Scotia, Ontario, Manitoba, and British Columbia (BC), Canada, as well as Norway, Germany and the United Kingdom (UK). Locked doors and units, and inaccessible physical spaces affect the balance between “home” and “institution” in LTRC facilities in numerous ways including privacy, mobility and autonomy of residents, the ability to remain socially connected within the home, possibilities of integration with the larger community and overall quality of life and care.

Promoting young people’s mental health and well-being through participation in the arts: A mixed-methods service evaluation of the Zinc Arts ArtZone programme

Abstract Arts-for-health initiatives are associated with improvements in mental health, wellbeing and social inclusion; however, research amongst young people is sparse. The aim of the study was to conduct a mixed-methods evaluation of a participatory arts programme for young people with, or at risk of, mental ill health. The Zinc Arts ArtZone programme involved working with individuals aged 11–25 in south-east England, engaging them in arts activities over ten-week courses in community and secure unit settings. 122 course participants completed pre/post measures of mental illness severity and well-being, and 34 participants took part in interviews and focus groups. Mental illness severity significantly decreased and mental well-being significantly increased. Participants reported social and emotional benefits including decreased social isolation and increased social inclusion and mental well-being. Participatory arts interventions may serve as a useful tool in tackling increasing mental ill health amongst young people.

Clozapine treatment of adolescent refractory emergent emotionally unstable personality disorder: Challenges in diagnostics and therapeutics

Despite recent advances precision diagnostic criteria on how best to diagnose and treat EUPD remains debated. Therapeutic indication and appropriate use of anti-psychotics including clozapine in this patient group remains unclear. It is debated about personality disorder being diagnosed in children and adolescents, overall it is much more acceptable for adolescents to be given a diagnosis of ‘emerging’ personality disorder if they exhibit clinical features of such. Clozapine has been used (as an off-license treatment) in adults diagnosed with personality disorder improving psychopathology and quality of life. These patients have been tried on numerous other treatments. In a secure unit for adolescent girls who meet the criteria for a diagnosis of emergent personality disorder who posed serious risks to themselves and others three were given a trial of clozapine The off license use of clozapine was tried in all three patients showed a reduction in incidents, reduced need for polypharmacy and improvement in their qualities of life. One cannot account for these changes being the result of clozapine alone; however, these cases add to the growing body of evidence of the benefits of clozapine in patients with emergent personality disorder.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Innovative Use of Interactive Doll Therapy in Addressing Management of Dementia with Behaviors and Reducing Antipsychotic Usage

One of the recent initiatives in geriatric medicine has been the push to decrease the usage of antipsychotics for treating dementia with behaviors in favor of non-pharmacologic interventions. We identified a high prevalence of antipsychotic usage in the secure memory care unit of our facility and became interested in studying alternative strategies to manage these residents. In looking at non-pharmacologic therapies currently available for patients with dementia, one therapy that has been growing in practice is doll therapy. In review of the literature, there is a growing body of recent evidence in favor of targeted doll therapy. However, none of those studies examined using an interactive doll. We decided to do a QA project using interactive dolls to see if this could help reduce antipsychotic usage in our secure unit.

Using the National Diabetes Audit to improve the care of diabetes in secure hospital in-patient settings in the UK

To examine the ability of two forensic units, one high secure and one medium secure, to meet the NICE (National Institute for Health and Care Excellence) standards of care for diabetes. We applied the National Diabetes Audit programme, which uses as standards the NICE guidelines, to assess the quality of care provided for patients in two forensic units. Of the 500 patients, 200 in high secure and 300 in medium secure, 88 (17.6%) had type 2 diabetes. None had Type 1 diabetes. Of those with Type 2 diabetes, the care of 74 (84%) met all 8 NICE recommended standards. Glucose levels were lower in the medium/low secure unit compared to the higher security environment. Whilst achievement of process-based outcomes was higher than those reported nationally, achieving clinical outcomes was more challenging. High-quality diabetic care can be provided for patients in forensic units. Benchmarking physical health outcomes against national criteria in mental health inpatients is a potential method of improving outcomes.

The effectiveness of self-soothing techniques for people with PTSD in secure units

The effectiveness of self-soothing techniques for people with PTSD in secure units