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A conceptual framework outlining the use of compassionate mind training following incidents of moral injury within forensic mental health servicesPurpose: Forensic mental health professionals often face challenging situations that can lead to moral injury. This occurs when individuals' experiences or actions conflict with their values and moral beliefs, leading to psychological distress or discomfort. Moral injury has been shown to be linked with a plethora of adverse psychological health outcomes, and can impair both occupational and personal functioning, including the quality of care delivered to service users. Design/methodology/approach: This paper details how forensic mental health professionals can respond to threat-based thinking, emotions and self-criticism using compassion following incidents of moral injury with compassionate mind training (CMT). Finding(s): CMT has been found to alleviate psychological distress and support development of soothing capabilities (Gilbert and Procter, 2006). Practical implications: This paper describes the central tenets of CMT and how it supports the balancing of three motivational systems: threat, drive and soothing systems. Originality/value: It further highlights the three flows of compassion: compassion from others, compassion towards others and compassion for self and how this can influence staff well-being in relation to moral injury. Copyright © 2025, Emerald Publishing Limited.
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Mechanical restraint in inpatient psychiatric settings : a systematic review of international prevalence, associations, outcomes, and reduction strategiesBACKGROUND: There is increasing emphasis on reducing the use and improving the safety of mechanical restraint (MR) in psychiatric settings, and on improving the quality of evidence for outcomes. To date, however, a systematic appraisal of evidence has been lacking. METHODS: We included studies of adults (aged 18-65) admitted to inpatient psychiatric settings. We included primary randomised or observational studies from 1990 onwards that reported patterns of MR and/or outcomes associated with MR, and qualitative studies referring to an index admission or MR episode. We presented prevalence data only for studies from 2010 onwards. The risk of bias was assessed using an adapted checklist for randomised/observational studies and the Newcastle-Ottawa scale for interventional studies. RESULTS: We included 83 articles on 73 studies from 1990-2022, from 22 countries. Twenty-six studies, from 11 countries, 2010 onwards, presented data from on proportions of patients/admissions affected by MR. There was wide variation in prevalence (<1-51%). This appeared to be mostly due to variations in standard protocols between countries and regions, which dictated use compared to other restrictive practices such as seclusion. Indications for MR were typically broad (violence/aggression, danger to self or property). The most consistently associated factors were the early phase of admission, male sex, and younger age. Ward and staff factors were inconsistently examined. There was limited reporting of patient experience or positive effects. CONCLUSIONS: MR remains widely practiced in psychiatric settings internationally, with considerable variation in rates, but few high-quality studies of outcomes. There was a notable lack of studies investigating different types of restraint, indications, clinical factors associated with use, the impact of ethnicity and language, and evidence for outcomes. Studies examining these factors are crucial areas for future research. In limiting the use of MR, some ward-level interventions show promise, however, wider contextual factors are often overlooked.
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Artificial intelligence in forensic mental health : a review of applications and implicationsThis narrative review explores the transformative role of artificial intelligence (AI) in forensic mental health, focusing on its applications, benefits, limitations, and ethical considerations. AI's capabilities, particularly in areas such as risk assessment, mental health screening, behavioral analysis, and treatment recommendations, present promising advancements for accuracy, efficiency, and objectivity in forensic evaluations. Predictive models and natural language processing enhance the precision of high-stakes assessments, enabling early intervention and optimized resource allocation. However, AI's integration in forensic mental health also brings significant challenges, particularly regarding data quality, algorithmic bias, transparency, and legal accountability. Limited access to high-quality, representative data can hinder reliability, while biases within AI models risk perpetuating existing disparities. Ethical concerns surrounding data privacy and the "black box" nature of many AI algorithms underscore the need for transparency and accountability. The review highlights future directions for responsible AI use, including improving data standards, fostering interdisciplinary collaboration, and establishing robust regulatory frameworks to safeguard ethical and fair AI applications in forensic settings. Balancing technological innovation with ethical considerations and legal obligations is essential to ensure AI supports justice and upholds public trust. This review calls for ongoing research, policy development, and cautious implementation to harness AI's potential while protecting individuals' rights within the justice system.
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Medication required : p*RN - promoting healthy attitudes and improved access to pornography in wathwood hospitalAims. The key aim of this project was to update and modernise the hospital procedure on how patients access pornographic material whilst detained at Wathwood Hospital. Within the update, we aimed to promote inclusivity and acceptance of all patients' sexual identities as well as utilising the opportunity to emphasise healthy consenting sexual relationships. Patients in Forensic Mental Health settings are often inpatients for a significant amount of time, with multiple restrictions imposed on their private and family life. Current policy allows patients to purchase pornography for private use in their own room. It must be material of the same nature available in a main street outlet. In practice, material is usually purchased in DVD format from the Amazon website and subsequently screened for suitability by Security staff and finally approval by the Responsible Clinician. There have been numerous incident reports involving the trading of pornographic material. Methods. Qualitative semi-Structured group interviews (up to 5 people at a time) were conducted with patients in the mediumsecure forensic services of Wathwood Hospital. They were recruited from the fortnightly Patient Forum. Anonymised questionnaires involving Likert scales and free text response spaces were also distributed at the Patient Forum. Data gathered investigated the percentage of patients who were aware of the current procedure, if they felt it worked well and what they thought the impact of accessing pornographic material might be. Staff were invited to complete a similar anonymised questionnaire, again considering their opinions on the positive or negative impacts of pornography for patients. In addition, we gathered data on whether there was a difference on the degree of comfort/discomfort about pornography, depending on whether the material involved opposite sex or same sex couples. In total, there were 40 survey participants. Results. Some key areas for concern were found, for example, only 17% of staff and 16% of patients thought the current policy works well despite 69% of staff and 84% of patients feeling it is a patient's right to access pornography. Free text and focus group feedback established many benefits to it. It was clear that there were some areas of difficulty in the hospital policy, which would benefit from being refreshed. Conclusion. Staff and patients overall feel that access to pornography is important for many of the patients. We identified areas for improvement in how this is accessed and a need to continually be considering the need to consider meeting the holistic needs for the patients.
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Collaborative risk assessment and management planning in secure mental health services in England: protocol for a realist reviewIntroduction Secure mental health pathways are complex. They are typically based around secure hospitals, but also interface with justice agencies and other clinical services, including in the community. Consideration of risk is fundamental to clinical care and to decisions relating to a patient’s stepwise journey through the pathway. Patient autonomy and involvement in decision-making are policy priorities for health services. However, improving collaboration in risk-related decisions in secure services is complicated by potential issues with insight and capacity and the necessary involvement of other agencies. In addition, although some collaborative approaches are feasible and effective, their impact, mechanisms and the contexts in which they work are not well understood. Therefore, using realist methodology, this review will outline what works, for whom, why and under what circumstances in terms of collaborative risk assessment and management in secure services. Methods and analysis The review will consist of four stages: (1) Development of an initial programme theory to explain how and why collaborative risk assessment and management works for different groups of people, (2) search for evidence, (3) data selection and extraction and (4) evidence synthesis and development of a final programme theory. Our initial programme theory will be informed by an informal search of the literature and consultation with experts and patient and public involvement and engagement representatives. Following this, our formal literature search will include both the published and unpublished literature. During full text screening, each document will be assessed according to the principles of rigour and relevance and, if included, data will be extracted and synthesised to refine the programme theory. Ethics and dissemination This protocol is for a review of published literature and so does not require ethical approval. The main output will be the final programme theory. Remaining gaps will inform planned future work to further refine the theory using mixed methods. Our dissemination strategy will be codeveloped with our public and patient involvement group and will include publishing findings in a peer-reviewed journal and presenting findings at relevant professional conferences, as well as engaging patient, carer and clinician groups directly.
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Reflecting on episodes of rapid tranquilisation in forensic MDT settingsAims. Rampton Hospital is the High Secure Hospital of Nottinghamshire Healthcare NHS Foundation Trust's Forensic Service. It is one of three such hospitals in England, following Security Directions set out by the Department of Health. Patient management occurs through the implementation of strict policies and procedures. Policy requirements highlight the need for MDT post-incident discussion of restrictive interventions, and in particular, of Rapid Tranquilisation (RT). This primary audit aimed to ascertain current practice and if necessary, suggest interventions to ensure that patient-care remains safe, effective, and well-led. Methods. To establish current practice with regards to the discussion of individual cases of RT in MDT settings, specifically in Ward Round, we commenced a retrospective data collection from electronic notes covering all directorates within the High Secure estate between May and June 2022. From these notes, we tried to ascertain whether the following policy standards were being met: * A de-brief with the patient should take place as soon after the incident as is practicable and reasonable, ideally within 72 hours. * The MDT meeting post RT episode should explicitly discuss the episode, and consider medication and any triggers of periods of acutely disturbed behaviour. * There were 81 data sets to explore. Results. Not all data sets were viable. Out of those analysed, less than 10% were found to have met the aforementioned ideal policy standards of having had a reflective discussion within 72 hours with both the patient and as an MDT, exploring the episode itself and its antecedents. Conclusion. There are several interesting factors to consider from the results obtained. We postulate that the frequency of episodes of RT makes meeting the policy standard problematic; pragmatically, there is a significant time barrier to exploring these incidents in detail and the various teams, operating in dynamic and highrisk environments, may find it difficult to coalesce in order to debrief appropriately. Furthermore, the reflections may actually be happening, but the burden of documentation mean that these are not being recorded formally in a way that can be measured. There are limitations to the searches of electronic notes and we did not have access to Incident Reports, often completed at the time of these episodes; further information may have been uncovered if they were available. Despite this, there is room for interventions that inform staff of this need and to provoke improvements in current practice.
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Physical Health Monitoring of Patients on Antipsychotic Medication at a Medium Secure UnitAims. People who have a serious mental illness have a higher prevalence of physical health problems as compared to the general population; with a 2-3 times greater risk of cardiovascular morbidity and mortality, double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome and five times the risk of dyslipidaemia than the general population. There is a concern that some antipsychotic drugs have metabolic consequences that contribute to the risk. As such, it is imperative that patients treated with antipsychotics receive appropriate health monitoring. Physical health monitoring of antipsychotic medications is an essential aspect of our practice, and despite assurance in previous audits, we agreed to monitor biannually to ensure we were maintaining standards. Additionally, this audit aimed to look more closely at special monitoring requirements for drugs such as Olanzapine, Chlorpromazine, Clozapine and Quetiapine which had not been measured in previous audits and would likely highlight some areas for improvement. Methods. Audit standards were drawn from the Maudsley Prescribing Guidelines in Psychiatry 14th edition, in addition to NICE Guidance CG178 - Psychosis and schizophrenia in adults: prevention and management. A random number generator was used to select patients from each of the 7 wards, giving a sample size of 21 patients. Data were collected on Weight, BP, ECG and various blood tests conducted from February 2021 - February 2022. Data was collected from a combination of patient electronic record, CPA reports, and online blood results system. Data were inputted to MS Excel which created percentage compliance in each domain. Results. 1. Blood Pressure: General compliance in the taking of BP met our standard of 100% 2. Weight: Annual monitoring compliance was 93% however compliance fell short for special recommendations for Clozapine, Olanzapine and Chlorpromazine. 3. ECG: Our compliance fell short in the recording of an ECG on admission, or at reaching target medication dose. Annual monitoring compliance was 93%. 4. Bloods: Annual compliance for FBC, LFT, U&Es, Lipids, Prolactin and 5. Glucose were 100%, however our compliance fell short for baseline recording and interim 3-6 monthly monitoring for various blood tests. Conclusion. Overall results demonstrate good, safe practice, particularly during a challenging period for clinical teams. Shortfalls particularly at baseline were related to risk issues making investigations impractical. It was agreed that there should be an increased frequency of regular glucose monitoring and that HbA1c monitoring was a reasonable measure for this.
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Metacognition, philosophy in prisons and the demands of rehabilitationAbstract This article sets out the case for providing regular philosophy sessions in prisons by focusing on its role in improving metacognition. We start by drawing attention to an important body of research on metacognition that is relevant to supporting prisoners in transitioning towards more prosocial lifestyles, as well as navigating the complexities of life both during and post-incarceration. We then make the case for offering philosophy programmes in prisons in order to help nurture and develop metacognitive skills in this population.
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Barriers and facilitators to increasing physical activity in medium secure mental health settings: An exploration of staff perceptionsPurpose: The benefits of physical activity for people with severe mental illness (SMI) is widely recognised but for those in medium secure settings there are additional environmental barriers to being active that have not been fully explored. The aim of this study was to explore the perceived barriers and facilitators from the perspective of staff within the medium secure setting. Method(s): Semi-structured focus groups were conducted with qualified and unqualified staff (n = 24) across two UK medium secure NHS settings. Michie's COM-B framework was used to inform the topic guide and the analysis of the data. Result(s): The opportunities to be active in medium secure settings depend not only on access to facilities but also staff availability and willingness to support such activities. When an individualised approach is taken, and staff are skilled and motivated to support such activities then it is possible for people with SMI in medium secure settings to be physically active. Conclusion(s): People with SMI in secure settings have reduced autonomy to increase their own physical activities but it was suggested that with the appropriate opportunities and the motivation of staff their capability to be active could be enhanced.
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IntroductionThe introduction explores some of the reasons why trauma has been overlooked in forensic psychology, despite its prevalence in forensic populations. Reasons include the complexity of the relationship between trauma and offending, difficulty in defining trauma and societal pressures that favour punishment over rehabilitation. Nevertheless, there is reason to believe that a trauma-informed approach may be a new paradigm in forensic psychology.
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First do no harmNo abstract available
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Risk Assessment and ManagementNo abstract available
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Reciprocal roles between therapies – a dialogueNo abstract available
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Challenging bias in forensic psychological assessment and testingChallenging Bias in Forensic Psychological Assessment and Testing is a groundbreaking work that addresses the biases and inequalities within the field of forensic psychology. It gives valuable insights into individual practices and wider criminal justice approaches at an international level, while providing tangible solutions to tackle the disparities. This book constructively critiques current forensic practice and psychological assessment approaches through a variety of diverse voices from pioneering researchers around the world who offer their expertise on these challenges and assist the reader to consider their potential contribution to pushing forward the frontiers of Forensic Psychology. The authors also locate the origin of these biases in order to further dismantle them, and improve the outcomes for the forensic client base – especially specific diverse populations. They emphasise the need to be creative and evolve not just in line with the real-world changes of today, but also to prevent the issues of tomorrow before they become the next news headline. This is a must read for professionals working in criminal justice, forensic psychology, legal psychology, and related fields. It is also a compelling resource for students and researchers of forensic psychology with particular interest in social diversity and inclusion.
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The validity of reconviction as a proxy measure for re-offending: Interpreting risk measures and research in the light of false convictions and detection and conviction evasion skills (DACES) and processesRisk assessment tools and intervention efficacy evaluations typically use reconviction as an outcome that is assumed to be a valid measure of the return to offending (RTO). Reconviction is however problematic as a measure of RTO because a significant amount of offending goes unreported, undetected and/or unconvicted. The consequences and implications of this measurement problem are significant for the forensic practitioner. In this chapter we outline the nature of this problem, highlighting one of the key differences between clinical formulation and actuarial assessment being that the former develops a causal model of offending behaviour whilst the latter is a largely atheoretical statistical account of factors correlating with reconviction (which is fundamentally different from RTO). We explore how clinical judgement may be predicting RTO, whereas actuarial assessment predicts reconviction (a smaller subset of those re-offending). The literature supports the idea that biases, such as racism and unequal detection and conviction rates for different groups of people, underpin convictions which are inevitably “baked in” (e.g., Mayson, 2019) to actuarial assessment; hence risk assessments are predicting outcomes that can be biased. The need to assess individual and systemic detection and conviction evasion skills and processes as part of assessment is highlighted, and a preliminary model for analysing systemic detection and conviction evasion skills and processes is presented. The importance of specifying a measurement model before interpreting reconviction as a “valid” outcome measure is highlighted
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Developing models and a framework for multi‐professional clinical supervisionThe UK government proposals for services for individuals considered to be dangerous with a severe personality disorder (DSPD) are developing. The complex task of balancing safety and therapeutic change in DSPD services will rest largely upon the skills, knowledge and practice of the staff group. As a result, one challenge for DSPD services is to provide sufficient training and support to staff, in order to ensure that adequate resources are available to assist them in processing their emotional reactions to their work. As part of this, clinical supervision systems need to be developed to offer professional support and learning, enabling individual practitioners to develop knowledge and competence and assume responsibility for their own practice (DoH, 1993). Among the service developments at Rampton Hospital an innovative multi‐professional supervision strategy has been introduced for all staff working in the unit. This paper describes the evolving supervision framework, including a new tool, the ‘Supervision Matrix’, and implementation guidelines, and describes how this supervision framework will be evaluated.
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Forensic mental health: Envisioning a more empirical future [In press]Summary Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.
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Elderly offenders at Wathwood Hospital: perspectives and practicalitiesAims. The following project explores where Wathwood Hospital stands in provision of services to its elderly patients. Background. The only dedicated forensic medium secure unit for elderly offenders in England is the St. Andrews medium secure unit in Northampton with only 17 beds. Due to the limited beds, other units must accommodate elderly patients, which raises the question whether these units can provide the appropriate services for this very vulnerable population. Method. Inclusion Criteria: Male >55 years of age Admitted from 2012 onwards (from when database was maintained) Data were gathered using patient electronic records including index offence, mental disorder, physical health comorbidities and discharge destinations. Patient identifiable data were anonymized to protect their identities. A staff survey was also conducted to find their perspective on managing elderly patients and whether Wathwood Hospital had the appropriate resources for elderly offenders in their area of work. Result. A total of 220 referrals were searched with only 9 patients >55 years. Index offenses, mental disorder diagnoses, physical comorbidities including cognitive assessments in the form of memory tests and brain imaging were also collated for identified patients from electronic patient records. Index offences included violence against person, arson, homicide, robbery, threatening behaviour and dangerous driving and affray. Diagnoses included learning disability, delusional disorder, paranoid schizophrenia, bipolar affective disorder, alcohol dependence, personality disorder and depressive disorder. Patients had multiple comorbidities such as diabetes, COPD, hypertension, coronary artery disease and musculoskeletal problems. Out of the nine admitted patients, only six had an ACE with an average score of 70.83. Five patients had brain imaging, with two normal results and the others showing some degree of atrophy and ischemic changes. Discharge destinations included medium secure units, low secure unit and prison. One patient unfortunately died during admission and four are still inpatients. A staff survey conducted showed their perspective on the challenges in managing elderly patients and whether Wathwood Hospital had the appropriate resources for them to work with elderly offenders in their area of work. All results will be explained through tables and graphs. Conclusion. It's evident that there are challenges in managing elderly patients in units not specifically designed to manage them. This is also due to the lack of geriatric training and resources available to allied health care professionals to carry out their respective work. It's therefore crucial we formulate more inclusive strategies to address these challenges.
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The improvement of the quality of medical reviews of patients in seclusion in Rampton HospitalAims. Improve and standardise the quality of medical seclusion reviews (MSRs). Acknowledge existing good practise. Highlight areas for improvement. Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP) Background. MSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR. Method. A retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients. The standard applied was the MHA CoP guidance for MSRs: 1) MSRs should be conducted in person, and should include: 2) Review of physical health 3) Review of psychiatric health 4) Assessment of the adverse effects of medication 5) Review of observations required 6) Reassessment of medication prescribed 7) Assessment of the patient's risk to others 8) Assessment of the patient's risk of self-harm 9) Assessment of the need for continuing seclusion 100% compliance with targets or a reason why it was not possible was expected to be documented. Result. The results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%. Conclusion. The quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.
