‘Monsters don’t bother me anymore’ forensic mental health service users’ experiences of acceptance and commitment therapy for psychosis

Acceptance and Commitment Therapy for psychosis (ACTp) is an approach that aims to change the relationship an individual with psychosis has with difficult thoughts, emotions and experiences. It promotes the use of acceptance, defusion, mindfulness and focussing on valued outcomes as opposed to struggling with psychotic experiences. This service evaluation project explored service users’ experiences and meanings of ACTp within a medium secure mental health service. Thematic analysis was used to analyse interviews with 10 male service users. Four main themes emerged from the data: ‘Recovery’, ‘Insight’, ‘Developing Skills’ and ‘Accessibility’. Overall, service users viewed their experience of ACTp positively and identified encouraging therapeutic outcomes. These findings suggest that ACTp is an approach that should be considered a therapeutic option within forensic mental health contexts. These outcomes were compared with previous research findings. Limitations of the study, clinical implications and ideas for future research have been discussed.     

Assessing change in dynamic risk factors in forensic psychiatric inpatients: relationship with psychopathy and recidivism

This study explored change in dynamic risk for violence using the Clinical and Risk Management subscales of the Historical Clinical and Risk Management-20 version 3 (HCR-20 v3) and sought to determine whether change was associated with violent recidivism. The association between the magnitude of change and psychopathy was also assessed. Participants were 40 male (n = 32) and female (n = 8) forensic psychiatric inpatients discharged from a secure forensic mental health service. Results showed that participants significantly improved on the HCR-20v3 Clinical subscale but significantly worsened on the Risk Management subscale. Psychopathy was unrelated to change in Clinical and Risk Management subscales. The hypothesis that changes in dynamic risk would predict recidivism over and above total pre-treatment risk (HCR-20v3 Total score) and psychopathy was not supported. These results suggest that improvements in mental state risk factors alone are insufficient with regard to lowering violence risk.     

Outcome measurement in forensic mental health research: an evaluation

Abstract

Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90–Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions.     

Forensic occupational therapy to reduce risk of reoffending: a survey of practice in the United Kingdom

Forensic services are required to reduce an individual’s risk of reoffending. Despite being integral to forensic mental health services, the contribution of forensic occupational therapy to achieving this aim is unclear. This study describes current forensic occupational therapy practice to reduce reoffending risk in the United Kingdom. Responses to a cross-sectional survey consisting of multiple choice and free-text questions were analysed using frequency counts and percentages, and thematic analysis respectively. Of the 58 participants, 83% actively addressed reoffending risk. Participants informed practice with occupation-focused theories, models and assessment tools. Five themes described forensic occupational therapy to reduce reoffending risk: an occupational perspective of risk assessment and formulation; volitional realignment; increasing protective factors; community integration; and enhancing understanding of forensic occupational therapy. Forensic occupational therapists perceive their practice to contribute to reducing reoffending risk, but are yet to establish routine outcome measurement in this area. Implications for practice and future research are discussed.     

Forensic Mental Health Clinical Evaluation: An Analysis of Interstate and Intersystemic Differences

Forensic mental health evaluation systems have undergone major changes during the past two decades, and the variability of service delivery systems across states is significant. We compared assessments of competence to stand trial and criminal responsibility in three states with different systems for forensic mental health evaluations: Michigan, Ohio, and Virginia. Although all three states use comparable legal criteria to judge competence and criminal responsibility, we found large, statistically significant differences among the states in the proportion of defendants referred for evaluation who were assessed as incompetent or not criminally responsible. In addition, significant differences were found in the diagnostic and offense categories of defendants referred for evaluation. Our findings suggest that the structure of a system for providing forensic evaluation services may significantly affect both the group of individuals referred for evaluation as well as evaluation outcome.     

A comparison of seclusion rates between intellectual disability and non-intellectual disability services: the effect of gender and diagnosis

Introduction: The use of seclusion as a means of managing the extreme behaviours forensic patients in secure settings is a controversial yet often common practice, despite there being little evidence that seclusion as a practice has any significant therapeutic value for the patient. The aim of this study was to explore the use of seclusion and whether this differs as a function of gender and diagnosis across secure services. Method: This study collated data from 11 medium and low secure hospitals that admit male and female patients, with some services providing services for patients with intellectual disability (with or without co-morbid disorders), and others for patients with mental illness and/or personality disorder only. Results: Both gender and diagnosis were associated with differential seclusion rates. Seclusions were three times longer for patients in the non-ID compared to the ID service. Male seclusions (for any diagnosis) were around twice as long as those in female services. Female ID patients spent significantly less time in seclusion compared to other groups. Female ID was associated with two to three times the number of seclusion events per patient compared to other groups. No statistically significant association between the type of service and the reason for a patient being secluded. Conclusions: A range of organisational factors that determine the use and duration of seclusion are cited and merit further exploration. High rates of psychiatric co-morbidity and the complexity of patients admitted to services may also mediate risk and use of seclusion. The study supports the use of early intervention techniques and the adoption of positive behaviour support.     

Community-based forensic child and adolescent mental health services in England,Scotland and Wales: a national mapping exercise

Aim: We sought to ascertain the current nature of specialist community mental health provision for young people presenting with risk of harm to others or involvement with the youth justice system in England, Wales and Scotland. Methods: Questionnaire-based survey. Results: Fifty-five services were contacted, 48 responded and 35 of these were found to be providing some form of community mental health provision to high-risk young people. Thirteen services provided comprehensive community forensic child and adolescent mental health (FCAMH) services, whilst the remainder offered more ad hoc clinical input. Amongst the comprehensive FCAMH services, staffing, function, commissioning arrangements and population served varied widely. Conclusions: There is patchy geographical provision of comprehensive community FCAMH services across England, Scotland and Wales with heterogeneous commissioning arrangements, staffing and function. Development of a national commissioning strategy for community FCAMH services is required to ensure that the complex needs of high-risk young people are adequately addressed.     

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.     

Working with personality disordered women in secure care: the challenge of gender-based service delivery

Abstract

Working with women in secure services is an infrequent subject of research and discussion in the forensic mental health literature. There are several reasons for this, which will be considered in the introduction to this paper. However, a consequence of this situation is that there remains a lack of clarity in key areas of practice in relation to working with women in secure services, and working with women with personality disorder specifically: how women with personality disorder may present in secure services compared to men, therefore, the particular skills required of the practitioners who work with women and the main design features of the services within which they are managed. The body of this paper attempts to summarise important issues in each of these areas in order to inform future debate and developments in the field.     

Head banging as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Introduction: ‘Head banging’ is a common form of self-harm, linked to numerous negative outcomes including significant brain damage. However, little research has investigated head banging behaviour and its correlates in clinical populations. Method: Head banging episodes were identified from the incident records (n = 5417) of two inpatient forensic services (one intellectual disability and one mental health), using relevant search terms. Rates were compared between individual patients, by gender, diagnosis and level of security. Incident accounts were analysed qualitatively using thematic analysis. Results: Head banging incidents occurred approximately every 3 days in each service, with 229 incidents recorded in 1 year. Individual patient rates varied widely, ranging from 1 to 38 incidents within 1 year. Women, and patients in higher levels of therapeutic security, were significantly more likely to engage in head banging. Qualitative incident reports indicated that head banging was associated with mental distress, anger and psychotic experiences. Discussion: Head banging occurs frequently in forensic services, and has documented associations with traumatic brain injury in affected individuals, thus negatively impacting progress through the care pathway and treatment outcomes. Further research should investigate short- and long-term management strategies and treatment approaches, in order to minimise harm.     

Comparison of HoNOS and HoNOS-Secure in a forensic mental health hospital

The Health of the Nation Outcome Scale (HoNOS) is a widely used tool for monitoring consumer outcomes within mental health services. However, concern about its suitability in forensic mental health settings led to the development of a forensic version of this tool (HoNOS-Secure). To date, no direct comparison of these versions has appeared in the empirical literature. In the present study, a cohort of forensic mental health consumers was rated using the HoNOS and HoNOS-Secure. Pearson correlations were generated to compare the tools at a total score and item level. Logistic regression was employed to evaluate how well these tools categorise patients on a range of measurable outcomes. HoNOS scores were also compared against civil mental health consumers to evaluate differences between these populations. The HoNOS/HoNOS-Secure correlated strongly at the total score level, but demonstrated variable correlations at the item level. Logistic regression suggested that the HoNOS-Secure ‘clinical and social functioning scale’ adds little to the HoNOS in a forensic setting; however, the HoNOS-Secure ‘security scale’ added significant benefit to both versions. Results remained stable when re-evaluated over time. Forensic and civil mental health patients were found to demonstrate the same degree of psychopathology at the point of admission; however, they differed at review and discharge collection occasions. Implications for clinical practice and policy are explored.     

A prospective comparative evaluation of a Criminal Justice Liaison and Diversion Service in Belfast

There is continued interest in the planning, development and implementation of services designed to identify detainees with mental illness and connect them to health and social services. However, currently, little is known about how best to configure, organise and deliver these services. The study employed a prospective follow-up design with a comparator group to describe and evaluate a police mental health liaison service based in Belfast. Participants were recruited from two neighbouring police stations, only one of which provided a mental health liaison service. Outcomes including mental health status, drug and alcohol misuse, risk-related behaviour and ‘administrative’ outcomes were assessed at the time of arrest and six months later. The service was successful in identifying and assessing detainees, though there appeared to be similar between-group levels of mental health problems over time. Results highlight a need to develop firmer linkages and pathways between criminal justice liaison/diversion services and routine health and social services.     

'Your personality is the intervention': a grounded theory of mental health nurses’ beliefs about hope and experiences of fostering hope within a secure setting

Hope is an important factor in psychological resilience and change, and recovery from mental health difficulties. Recently, there has been an increased focus on recovery-oriented practice within forensic mental health settings. Several policies include calls for mental health practitioners to inspire hope for recovery in the individuals they work with. However, there is little suggestion of how to implement such recommendations in practice or research exploring how staff foster hope in forensic settings. This study used grounded theory to explore nurses’ perspectives and experiences of hope within a medium secure setting. A model was developed from the data that integrated nurses’ beliefs about hope, practices to develop service users’ hope and the emotional impact of this work. The nurses’ values played a significant role in their work to develop hope. Recommendations are made to help manage the emotional impact and address challenges unique to fostering hope within forensic settings.     

A tale of two cultures: examining patient-centered care in a forensic mental health hospital

Several questions remain unanswered regarding the extent to which the principles and practices of patient-centered care are achievable in the context of a forensic mental health hospital. This study examined patient-centered care from the perspectives of patients and providers in a forensic mental health hospital. Patient-centered care was assessed using several measures of complementary constructs. Interviews were conducted with 30 patients and surveys were completed by 28 service providers in a forensic mental health hospital. Patients and providers shared similar views of the therapeutic milieu and recovery orientation of services; however, providers were more likely to perceive the hospital as being potentially unsafe. Overall, the findings indicated that characteristics of patient-centered care may be found within a forensic mental health hospital. The principles of patient-centered care can be integrated into service delivery in forensic mental health hospitals, though special attention to providers' perceptions of safety is needed.     

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

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

An evaluation of the Enhanced Thinking Skills (ETS) programme with mentally disordered offenders in a high security hospital

Purpose. Further to evidence of the successful application of cognitive skills programmes with offenders in HM prison service, the Enhanced Thinking Skills (ETS) training course is now delivered in various secure forensic hospitals, and its usefulness with an offender patient population merits examination. Our aim was to evaluate the impact of ETS using measures designed to capture change in key areas targeted by the course, and a more global measure of mental well‐being. Methods. Offender patients (N = 83) referred for ETS between 2001 and 2006 via a wider groupwork service within a high security hospital were administered questionnaires before and after the training course, which was minimally adjusted to meet the needs of the patient population. Attendance rates, including ‘drop‐out’ (completion of 10 or less sessions) were recorded. Demographics by subgroup (completers vs. non‐completers), and the clinical significance of any changes endorsed by participants post‐group were examined. Results. ETS completers were significantly more likely than non‐completers to endorse changes in thinking style (e.g. a reduction in post‐course scores). Significant differences were observed at both the group and individual level in the direction of less externalization of blame, a slight increase in tolerance of frustration, an increase in social conformity, and improvement in critical reasoning skills. Furthermore there was a reduction in the endorsement of aggressive solutions to social problems. Conclusions. These findings demonstrate a significant short‐term impact of the course for mentally disordered offenders with regards change in aspects of their thinking style and enhancement of their social problem solving skills. This profile lends some support to the provision of ETS within secure hospital settings.     

Demographic and clinical characteristics of 1092 consecutive police custody mental health referrals

The 43 police forces in England and Wales have made over 13 million arrests in the last decade. Yet, despite this high volume criminal justice system activity, and evidence of substantial health morbidity across the criminal justice pathway, mental health services in police custody have only been patchily developed, and the literature in this area is limited. Referrals (n = 1092) to a pilot mental health service operating across two police stations in a London borough were examined over an 18-month period in 2012/2013. The referred group had high levels of mental health and substance misuse problems (including acute mental illness, intoxication and withdrawal), self-harm, suicide risk and vulnerability (including intellectual disability), with some important gender differences. Although this work has limitations, the findings are broadly consistent with the small existing literature and they confirm the need for services that are sufficiently resourced to meet the presenting needs.     

Characteristics of female patients admitted to an adolescent secure forensic psychiatric hospital

Bluebird House is the only mixed gender NHS secure forensic psychiatric hospital for adolescents in the South of England. It has admitted more than 30 female patients since the service opened in 2008. The admission criteria are that patients must be detained under the Mental Health Act and present evidence of being a risk of harm to others. This article describes the clinical characteristics of 30 consecutive female patients admitted to a highly specialised adolescent forensic inpatient service. Key results include a very high rate of incidents of risk behaviours exhibited by female patients within the unit but good clinical outcomes. The majority of patients had severe symptoms of mental disorder, especially emotional instability, self-harm behaviours and aggressive behaviours. Few had diagnoses of mental illness. Assessment findings from the Millon Adolescent Clinical Inventory and the Structured Assessment of Violence Risk are discussed, as are parallel with studies from other female secure services.     

Cloud forensics–Tool development studies & future outlook

In this work, we describe our experiences in developing cloud forensics tools and use them to support three main points:First, we make the argument that cloud forensics is a qualitatively different problem. In the context of SaaS, it is incompatible with long-established acquisition and analysis techniques, and requires a new approach and forensic toolset. We show that client-side techniques, which are an extension of methods used over the last three decades, have inherent limitations that can only be overcome by working directly with the interfaces provided by cloud service providers.Second, we present our results in building forensic tools in the form of three case studies: kumodd–a tool for cloud drive acquisition, kumodocs–a tool for Google Docs acquisition and analysis, and kumofs–a tool for remote preview and screening of cloud drive data. We show that these tools, which work with the public and private APIs of the respective services, provide new capabilities that cannot be achieved by examining client-side artifacts.Finally, we use current IT trends, and our lessons learned, to outline the emerging new forensic landscape, and the most likely course of tool development over the next five years.