Therapeutic jurisprudence and mental health tribunals: changing patterns of demand and its impact

For decades the mental health system has been ‘in crisis,’ with too little funding, too much demand and fragmented services. In England and Wales, decisions made concerning the care and treatment of those suffering from a mental disorder is governed by the Mental Health Act 1983 (as amended) (MHA 1983). Detention under the legislation is fraught with conflict; patient and clinical views are often at odds. Mental health tribunals enable patients to seek a review of their case and the legality of their detention. This paper argues that with the increased use of formal detention under the MHA 1983, the caseloads of mental health tribunals have similarly risen. Whether it is possible to advance therapeutic benefit to psychiatric patients attending tribunals is open to question. While mental health tribunals have a role to play in generating a positive psychological impact on an applicant, there is a risk that time and resource pressures may inhibit the adoption of a therapeutic approach. This paper considers the key drivers that are currently pushing detention rates up, the impact this is having on mental health tribunal caseloads and whether it is possible to bring therapeutic jurisprudence to the patient.     

Physical restraint in polish psychiatric facilities

Physical restraint in the form of direct force, forced feeding and medication, mechanical restriction of bodily movement, or the threat of force was administered to close to 30% of patients admitted and hospitalized for a period of at least fourteen days. In transporting the patient to the admission room and then to his treatment ward, the dominant form of restraint used was direct force, or the threat of such force. During the following fourteen days of hospitalization, mechanical restraint and forced medication predominated. Restraint was applied most often, across each of the four phases of the study, to patients deemed dangerous to self or others. This relationship became significantly stronger as the period of hospitalization continued. Across the four phases, patients who protested their hospitalization were more likely to be restrained than patients who agreed to it or who did not object. During each of the four phases of the study, numerous patients who did not object to their hospitalization and who were not deemed dangerous were nevertheless subjected to restraint. The pervasiveness of physical restraint, the wide inter-hospital differences in its use, the apparent over-prediction of patient dangerousness, and the use of restraint with patients who were not deemed dangerous and who did not object to their hospitalization, confirms the need for legal and ethical regulation of physical restraint of psychiatric patients.     

Medicare and Medicaid programs; hospital conditions of participation: patients' rights. Final rule

This final rule finalizes the Patients' Rights Condition of Participation (CoP) which is applicable to all Medicare- and Medicaid-participating hospitals and contains standards that ensure minimum protections of each patient's physical and emotional health and safety. It responds to comments on the following standards presented in the July 2, 1999 interim final rule: Notice of rights; exercise of rights; privacy and safety; confidentiality of patient records; restraint for acute medical and surgical care; and seclusion and restraints for behavior management. As a result of comments received, we have revised the standards regarding restraint and seclusion and set forth standards regarding staff training and death reporting.     

Restraint-related fatalities in mental health facilities: report of two cases

Mental health facilities are occasionally confronted with patients who display destructive or disruptive behaviors requiring physical restraint. Under these circumstances, restraint can be associated with death. This case report describes two fatalities associated with physical restraint applied by staff members at mental health facilities.     

Physical restraint in a therapeutic setting; a necessary evil?

Physical restraint of people experiencing mental health problems is a coercive and traumatic procedure which is only legally permitted if it is proportionate to the risk presented. This study sought to examine the decision-making processes used by mental health staff involved in a series of restraint episodes in an acute care setting. Thirty nurses were interviewed either individually or in focus groups to elicit their views on restraint and experience in specific incidents. Four factors which influenced the decision to restrain were identified: contextual demands; lack of alternatives; the escalatory effects of restraint itself; and perceptions of risk. While some of these factors are amenable to change through improvements in practice, training and organisational culture, nurses viewed restraint as a necessary evil, justified on the basis of the unpredictable nature of mental illness and the environment in which they worked.     

Therapeutic jurisprudence and responsivity: Finding the will and the way in offender rehabilitation

Correctional systems worldwide are currently undergoing a shift towards rehabilitation. Underpinning rehabilitation are the principles of risk, need, and responsivity. Responsivity includes internal responsivity (offender characteristics) and external responsivity (staff and setting characteristics). The responsivity principle has been neglected in the literature. While contemporary psychological theories of offender rehabilitation address internal responsivity, they do not address external responsivity, particularly in relation to the impact of the law. Therapeutic jurisprudence as a legal theory provides the opportunity to complement psychological theory and to address responsivity in offender rehabilitation. Therapeutic jurisprudence utilizes psychological knowledge to determine ways in which the law can enhance individual well-being. The purpose of this article is to demonstrate a psycholegal approach to offender rehabilitation. Psychological approaches can be applied to motivate offenders and provide them with the opportunity to make informed decisions about participation in rehabilitation programmes. However, this approach will not succeed without harnessing correctional staff as legal actors and potential therapeutic agents. A cognitive--behavioural model of an organizational culture change towards rehabilitation is proposed. In this endeavour “the will and the way” in both offenders and staff can be harnessed to maximize the therapeutic effects of the law.     

The sources and consequences of corrections officers' stress: A South Korean example

Corrections officers play crucial roles in the functioning of correctional institutions. They create and maintain the social and security milieu within prisons and often have direct impact on the behavior of inmates through their daily contact with inmates. Studies showed, however, that the correctional work environment was fraught with stress. Many studies found that corrections officers experienced excessive stress, which manifested in physical illnesses, burnout, family problems, or their inability to perform their duties—compromising institutional safety and creating further stress for other staff. These studies were instrumental in instituting improvements in the correctional work environment; however, most were conducted in Western societies. To extend the knowledge of corrections officers' work environments, this study examined correctional work among officers in South Korea. Specifically, stress-related issues outlined in previous studies were examined here to assess their relevance and applicability in the South Korean society. Implications for policy and future endeavors are discussed.     

How do professionals experience working with offenders diagnosed with personality disorder within a prison environment?

To explore the different experiences of a Multidisciplinary Team working with offenders diagnosed with personality disorder (PD) and produce a substantive model of the Offender PD Pathway strategy from a staff perspective. Fourteen participants were recruited from ‘Unit A’ located within a high security prison. Semi-structured interviews were conducted with participants and the data collected were analysed using constructivist grounded theory. A model was constructed depicting the experiences of those working with offenders with PD. Main themes identified were: prison environment; synergy of the workforce; understanding of the client; individual perceptions; support; and personal change. Although there was enough similarity within the participants’ responses to consider them to be a homogenous population, there were some noticeable differences in trends of responses evident between the two sub-groups of health service-based clinical staff and prison staff as expressed in the model. There is interplay between factors which influence an individual’s experience of working with offenders with PD. How a member of staff experiences working with offenders with PD depends on more than just the nature of the client and the challenges they pose. These factors external to the client group appear to have a significant impact on the professional and their emotional experiences of their work.     

In the wake of a negligent release law suit

Several staff members at a state psychiatric hospital were found negligent in a jury trial for having released a psychiatric patient who subsequently killed a member of the plaintiff's family. This study explored the impact of the law suit on the hospital staff members as individuals and on the functioning of the institution. Self-report measures revealed that both named defendants and nondefendant staff experienced symptoms of emotional disturbance associated with the litigation. Self-report measures suggest that the law suit was not instructive in any meaningful way regarding improved procedures for subsequent release decision making. Archival data indicate that the staff did release significantly fewer patients during the trial and follow-up period than prior to the litigation. Results are discussed in the context of Wexler's concept of therapeutic jurisprudence.This study was supported by a grant from the Research Grants Committee of the University of Alabama. The results are the opinions of the authors and do not reflect the opinions of the Research Grants Committee or the University of Alabama. We are indebted to Saleem Shah for his suggestions regarding methodology and particularly the need to investigate positive and instructive aspects of law suits.     

Is sexually abusive behaviour in personality disordered inpatients analogous to sexual offences committed prior to hospitalization?

Abstract

Sexually abusive behaviour by personality disordered patients presents a serious threat to the integrity of staff–patient relationships and the safety of other residents. The occurrence of such behaviour is also problematic for the offending patient, as it may impact on perceived treatment needs and their access to the community. This paper reports on a study of sexually abusive behaviour in a high security psychiatric hospital. It also examines the relationship between these behaviours and patients’ history of sexual offending. The results showed a high frequency of low-severity sexually abusive behaviour and no significant associations between sexually abusive behaviour during hospitalization and sexual offence history. These findings imply that low-severity sexually abusive behaviour within secure settings may be determined, partly, by environmental conditions. This sexual abuse may also be functionally dissimilar to severe sexual abuse perpetrated in the community. The meaning and determinants of sexual abuse within secure settings must be scrutinized carefully and comprehensively before they are considered analogous to previous sexual offences.     

浅析人员反应对火灾风险评估的影响

通过探讨人员反应可能对火灾发生造成的影响及分析安全人员采取行动的起始时间分布,给出一种考虑人员反应的风险评估方法的基本框架并分析其优劣,表明了定量考虑人员反应的可能性。对于进一步发展风险评估方法具有借鉴意义。     

Physical Restraint and Near Death of a Psychiatric Patient

Physical restraint is used as a last resort emergency measure to calm and safeguard agitated and/or aggressive psychiatric patients. This can sometimes cause injuries, and rare fatalities have occurred. One mechanism of injury and death while in physical restraint is that of severe asphyxiation. We present the case of a hospitalized man in his mid‐30s, suffering from schizophrenia. The patient was obese. He became aggressive and had to be manually restrained with a “takedown.” After having been put in the prone position on the floor with a significant weight load on his body, he lost respiration and consciousness. Subsequently, he was given CPR. He regained consciousness and respiration, while the cyanosis receded in 1–2 min. Psychiatrists and pathologists should be aware that physically restraining a patient in the prone position with a significant weight load on the torso can, in rare cases, lead to asphyxiation.     

Effects of a state law on rates of restraint on a child and adolescent unit

Rates of restraint and seclusion on a child and adolescent unit were evaluated before and after the implementation of a restrictive state law which was designed to reduce the monthly rates of restraint. Overall, the total number of hours in restraint, corrected for mean daily census, decreased significantly. The average number of patients in chemical restraint stayed about the same. There was a significant increase in number of patients, number of episodes, and hours of mechanical restraint as expected. Rates of seclusion dropped to zero as mandated. A new category of physical restraint was defined by law and was used to limited extent.     

A systematic review of effective therapeutic interventions and management strategies for challenging behaviour in women in forensic mental health settings

Women in secure forensic mental health care require therapy and care that is responsive to their specific needs. Despite the policy recognition that women require a distinct service, evidence based practice is not available for this population. This review was undertaken in response to a clinical need within a medium secure unit in Glasgow that was experiencing high levels of challenging behaviour, in a female ward. The review aimed to identify effective strategies or interventions for the management of challenging behaviour in women in secure services and, therefore, improve practice and patient care. A synthesis of the findings from the 11 identified studies revealed variability in the approaches used to support women in forensic services, including: behavioural programmes; organisational change with a focus on staff training and support; medication; ECT and mechanical restraint. The challenging behaviours assessed included self-harm; physical and verbal aggression; suicide attempts and arson/fire setting. The majority of articles suggested some improvement in aspects of challenging behaviour, however this was limited by the lack of control groups and small sample sizes. Further investigation is required to find out whether interventions identified in this review can sustain a reduction in challenging behaviours in the long-term.     

The importance of staff practice in delivering effective correctional treatment: a meta-analytic review of core correctional practice

Several meta-analyses have rendered strong support for the clinically relevant and psychologically informed principles of human service, risk, need, and general responsivity. However, each of these reviews has focused on specific program components and not on the characteristics of the staff or the specific techniques used to deliver the program. This meta-analytic review examines the role of core correctional practices in reducing recidivism and provides strong preliminary evidence regarding their effectiveness. Staff characteristics and training in core skills must be addressed to ensure the maximum therapeutic impact of correctional treatment programs.     

Building from the ground up: exploring forensic mental health staff’s relationships with patients

Recovery-orientated care is becoming generally accepted as the best practice, and continued development in the ways it is practiced is necessary to ensure improvement of ongoing care. Forensic patients often experience double stigmatization (the dual stigma of mental illness and offending behaviour) and during admission to hospital may lose touch with their community supports. While working through their personal recovery, patients develop therapeutic relationships with their multidisciplinary team members. When positive, these relationships can enhance a patient’s recovery. Clinical staff members participated in 88 in-depth interviews, which were transcribed, reviewed, and analysed using thematic analysis. From analysing the data, main themes and subthemes emerged related to staff’s perceptions of therapeutic relationships. When developing relationships, staff need to overcome receptiveness issues by increasing trust through understanding their preconceptions, reducing stigma, sharing innocuous stories, and giving patients the time they need. The key pillar underpinning all traits ascribed to patients and staff is collaboration and approaching treatment protocols with a social approach is essential to enhancing recovery. Staff shared a holistic view of recovery that incorporated the benefits of positive relationships and the need to create a sense of home within the institution.     

Leave it at the gate: job stress and satisfaction in correctional staff

Though academic literature firmly establishes an inverse relationship between job stress and job satisfaction, global correctional studies fail to examine the extent of that affiliation on overall correctional job satisfaction. As such, this study uses a faceted approach to explore underlying relationships between organizational, job, and personal characteristics of correctional staff and causes of job stress and satisfaction. Using the Job Satisfaction Survey, nine aspects of job satisfaction are considered. The Work Stress Scale for Correctional Officers’ analyses of five areas of stress directly related to correctional environments. This study examines both uniform and nonuniform staff assigned to a minimum security prison. On average, staff scored well below the average American worker on the Job Satisfaction Survey. Job satisfaction was predicted exclusively by job characteristics or stressors, including the job itself, role conflict, and ambiguity, and the physical condition of the prison, while employee demographic variables and variables that measure healthy lifestyles (such as sleep and exercise) were not significant predictors. While job stress does predict a substantively significant portion of job satisfaction (21%), there is still room to improve prediction.     

The evolution of security industry regulation in the European Union

ABSTRACT

The European private security sector has grown from a handful of small companies at the end of the Second World War into a multibillion Euro industry with thousands of firms and millions of security staff. In Europe, the demands for security is not just expressed notionally but also officially in The European Agenda on Security stating the European Union (EU) aims to ensure that people live in an area of freedom, security, and justice. This article will begin by exploring the role of private security in society. It will then move on to consider the main phases in the development of private security regulation in Europe. Following on from this, some of the main areas of policy development will be considered, such as European bodies, initiatives, and standards. Finally, the article will explore some of the potential options for the future in better regulating the European private security sector. From a historical perspective, the evolution of private security regulation can be divided into three phases: the laissez-faire, the centrifugal, and the centripetal era – each with its own distinct characteristics and impact on the concurrent industry. In the EU where there is the legal framework for the development of a single market in services, the key social partners have been at the forefront of developing a series of standards and guidance documents which promote standards across borders at the European level. However, the institutions of the EU have been reluctant to intervene at a European level in setting minimum standards of private security regulation. Thus, the changing terrain of the EU relating to security, regulation, and the private security industry means the current trajectory may be in need of an injection of more radical thought and consideration.     

Trauma Systems Therapy in Residential Settings: Improving Emotion Regulation and the Social Environment of Traumatized Children and Youth in Congregate Care

Although abundant evidence exists indicating the prevalence of trauma exposure among youth in residential care, few models exist for creating trauma-informed milieu treatment. This article outlines the problem and describes the implementation of Trauma Systems Therapy (TST) in three residential centers. TST is unique in emphasizing youth emotions and behaviors as well as the role a distressed or threatening social environment may play in keeping a traumatized youth in a dysregulated state. This dual emphasis makes TST specifically appropriate to implementation in congregate care, focusing assessment and intervention strategies on both clinical treatment and the functioning of the therapeutic milieu itself. Data are reported on incidents of the use of physical restraint; numbers of disrupted foster care placements following discharge from residential treatment; and scores on psychometric measures of children’s functioning and emotion regulation capacity. Knowledge gained through TST implementation in these three residential centers has important implications for developing a model of trauma-informed congregate care.