• A clinical database for measuring outcomes in a low-secure service: A feasibility study

      Edworthy, Rachel; Khalifa, Najat (2014)
      Purpose - The purpose of this paper is to present the arguments for sustaining a clinical database, assess its feasibility in a low-secure service, examine the data that can be captured and discuss what this means for practice implications and service development. The paper aims to demonstrate how a clinical database can provide information on three key areas: what patients are like before admission, what is done with them whilst they are in hospital and what happens to them when they are discharged. The paper also aims to examine the practical, legal and ethical implications of building such a database. Design/methodology/approach - This is conducted in the form of a feasibility study charting the development and implementation of an inpatient clinical database for a low-secure inpatient service. Findings - The feasibility of creating and maintaining a clinical database in a low-secure service has been assessed and the paper has found that they are an invaluable source of data that all mental health services should strive to develop. They will enable services to track their own outcome measures and tailor their service and interventions according to the needs of service users. However, ethical and legal issues surrounding building clinical databases are complex and require careful consideration. Research limitations/implications - This is a small-scale study that captured the experience of one service. Ideally this research should be expanded with nationwide clinical database development. Practical implications - This paper includes implications for the implementation of a clinical database, the resources needed for the running of this and the development of standardised outcome measures for mental health services. Originality/value - This is potentially an innovative way of developing a clinical database for a low-secure unit and some of the first research into the feasibility of a database for this population. Its practical application is relatively new and potentially innovative in how it is applied.
    • A description of two patients with Type 1 diabetes living in a high secure psychiatric hospital: Their journey moving from fixed dose to self-directed variable dose insulin using an individualised adaptation of the Bournemouth Type 1 Intensive Education (BERTIE) Programme and a unique calculation tool

      Edson, D.; Humphries, Tom (2014)
      The High Secure Pychiatric Hospital treats mentally unwell people who are a 'grave and immediate danger to themselves and/or others' [1].It is one of only three high secure hospitals in the country and has its own health centre with associated staff. This project aimed to educate two patients with Type 1 diabetes in carbohydrate counting and insulin dose adjustment. Historically patients have been prescribed fixed dose insulin to avoid errors and potential self-harm. Allowing them to calculate their own fast acting insulin doses was initially met with resistance from care teams at this hospital; however, changes in working relationships has produced a collaboration of care providing improved outcomes for health. Empowering patients with learning difficulties and low numeracy skills to calculate and adjust their fast acting insulin has been shown, in two cases, to improve glycaemic control. The principle of calculating a correction dose, estimating the carbohydrate in any food or drink and administering a dose of fast acting insulin was taken from training done by educators on the BERTIE Programme. The programme was adapted in timescale (to allow for extra education) and delivery. Individual sessions allowed for the complex needs of the patients and a unique calculation tool or 'slide rule' was developed to aid the process. Working with healthcare professionals across all specialities these patients now show improved biochemistry and health outcomes.
    • A mental disorder of a kind or degree warranting confinement: Examining justifications for psychiatric detention

      Bartlett, Peter (2012)
      It has long been the case in jurisprudence under the European Convention on Human Rights that mental disorder must be of a certain severity in order to justify detention, but there has been little meaningful debate as to what that means. The question is relevant not merely to the European Court of Human Rights, but also to the Committee for the Prevention of Torture, as the potential of inhuman or degrading treatment that arises from the coercive elements in institutions is particularly clear if persons are wrongfully detained in an institution and ought in fact to be somewhere else. Considerable improvement in the substantive clarity of domestic law is therefore required. The specifics of the domestic standards are a matter for individual governments but, within the Council of Europe, they will need to meet the requirements of both the European Convention on Human Rights and the United Nations Convention on the Rights of Persons with Disabilities. The article considers the traditional justifications for civil detention in psychiatry - dangerousness, need for treatment and capacity - in the light of these two conventions. © 2012 Taylor & Francis.
    • A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

      Vollm, Birgit A. (2017)
      Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for 'long stay'; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay. To (1) estimate the number of long-stay patients in secure settings; (2) describe patients' characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients' perceptions of their treatment and quality of life; and (4) explore stakeholders' views on long stay. A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4). All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England. Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4). Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient's admission and the current section of the Mental Health Act [Great Britain. Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving 'around' between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of 'cure' does not work with this group. We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients. The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain. To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients. The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376. The NIHR Health Services and Delivery Research programme.
    • A multi-method evaluation of a substance misuse program in a medium secure forensic mental health unit

      Oddie, Sharon (2009)
      Evidence suggests a complex relationship between substance misuse, mental health, and violence in forensic populations, however, the majority of existing research and interventions focus on these factors individually. This paper reports an evaluation of the first module of an integrated poly-substance misuse group delivered within a medium secure mental health hospital, which was designed to address these factors collectively. Qualitative and quantitative approaches were used to assess participant's subjective views of the program and to gather pre and post quantitative measurement of change. The concordance between self report and observer reportswas explored.Recommendations for the development of the treatment and for further evaluation and research are discussed.
    • A multidisciplinary approach to team nursing within a low secure service: The team leader role

      Davies, Jason (2012)
      PURPOSE: This article critically examines the clinical utility of redesigning a nursing practice model within the Intensive Support and Intervention Service, a new low secure mental health facility in the United Kingdom. Specifically, the "team nursing" approach to care delivery has been adapted to consist of multidisciplinary team leaders as opposed to nursing team leaders. FINDINGS: The authors describe the role, properties, and functions of the multidisciplinary team leader approach. The authors provide examples of the benefits and challenges posed to date and the ways in which potential barriers have been overcome. PRACTICE IMPLICATIONS: Nursing care leadership can be provided by multidisciplinary staff. An adapted model of team nursing can be implemented in a low secure setting. © 2011 Wiley Periodicals, Inc.
    • A preliminary study of violent incidents in a special hospital (Rampton)

      Larkin, Emmet P.; Murtagh, Sylvester; Jones, Sue (1988)
      A six-month prospective study of violent incidents was carried out in a Special Hospital (Rampton). Comparisons were made with results from earlier studies in general psychiatric hospitals. As might be expected, incidents occurred more frequently in the Special Hospital. These incidents were also more serious in nature and resulted in greater injury. Although more patients in the Special Hospital were involved in incidents, only a small number of patients accounted for the majority of these. Female patients, who comprised 25% of the Special Hospital population, were involved in 75% of the incidents. Nursing staff were three times as likely to be assaulted as patients.
    • A retrospective evaluation of a therapeutic community for mentally disordered offenders

      McMurran, Mary; Egan, Vincent (1998)
      This paper reports a retrospective evaluation of a therapeutic community (TC) for mentally disordered offenders in a regional secure unit (RSU). All 85 patients who had passed through the TC since it opened in 1987 were eligible for the study. Information on 81 patients was available in clinical records, providing a descriptive profile of the population. Information on recidivism was collected from the Home Office Offenders Index for 53 patients, providing information on effectiveness of the TC in terms of its impact on crime. Those for whom post-discharge crime information was collected were split into assessment and treatment groups, and short- and long-stay groups. All patients significantly reduced their offending after discharge as compared with pre-admission levels. There was no significant difference between the assessment and treatment groups, or between short- and long-stay groups. Whilst there was a significant overall reduction in offending, this cannot be attributed to the TC programme. Programme design, selection criteria and pre-admission assessment all require further attention to optimize the effectiveness of group treatment for mentally disordered offenders.
    • A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine

      Cormac, Irene; Brown, Adrian R.; Ferriter, Michael; Huckstep, Bernard (2010)
      Objective: To investigate the effect of a complete smoking ban on a group of psychiatric inpatients maintained on the antipsychotic medication clozapine.; Method: Retrospective data on clozapine dose and plasma levels were collected from a three month period before and a six month period after the introduction of the smoking ban.; Results: Before the ban only 4.2% of patients who smoked had a plasma clozapine level > or =1000 microg/l but after the ban this increased to 41.7% of the sample within the six month period following the ban despite dose reductions.; Conclusion: Abrupt cessation of smoking is associated with a potentially serious risk of toxicity in patients taking clozapine. Plasma clozapine levels must be monitored closely and adjustments made in dosage, if necessary, for at least six months after cessation.;
    • A study of absconding by special hospital patients: 1976 to 1988

      Shubsachs, Alexander P. W. (1993)
      Absconding by Special Hospital patients is taken seriously and attracts considerable attention; however, there has been no published research on the topic. The present study looks at the demographic details of Special Hospital absconders over a 13-year period and at characteristics of the absconding events. The absconding group was compared with a control group admitted during the same period. Absconding was rare, In most cases the duration was short, with all absconders being eventually found, 33 per cent returning of their own accord. There was an excess of patients with a classification of psychopathic disorder in the absconding group and fewer with a classification of mental illness. Absconders rarely offended whilst at liberty and with two exceptions such offences were trivial in nature. There was a preponderance of patients with psychopathic disorder in the group that offended whilst at liberty. Apart from the group who offended when at large the absconsion did not seem to hinder subsequent discharge. Predictors for absconding were not found. Overall the study endorsed the security measures taken by the Special Hospitals. © 1993 Taylor & Francis Group, LLC.
    • A systematic review of psychopathy in women within secure settings

      Beryl, Rachel; Vollm, Birgit A. (2014)
      The construct of psychopathy has been comparatively understudied in women, and to date there has been no attempt to systematically review the literature related to psychopathy in women. This review assimilates the existing evidence in relation to the prevalence and factor structure of psychopathy in women within secure settings. An extensive systematic search was performed using 11 electronic databases and four search engines; citation, author and reference list searching was also performed. After removing duplicates and appraising the study's eligibility by title, 261 publications were appraised against minimum quality and eligibility threshold criteria, resulting in 28 remaining publications with data on 2545 participants. Quality appraisal was conducted by two raters, with excellent inter-rater reliability (kappas = .7-.9). A narrative synthesis was then performed. PCL-R based prevalence rates ranged from 1.05% to 31% (with a cut-off criterion of 30), with variations in multiple factors, such as geographical location and type of sample setting. The factor model with the most support from the reviewed studies was Cooke & Michie's (2001) 3-Factor model. The apparent gender differences in the prevalence rates, factor structure and item expression of psychopathy, presents implications for the assessment and general conceptualisation of the construct in women within secure settings. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • A test of methodology intended to assist detection of aggressive offence paralleling behaviour within secure settings

      Daffern, Michael; Howells, Kevin; Mannion, Aisling; Tonkin, Matthew (2009)
      Purpose. Treatments and risk assessments determined by the offence paralleling behaviour (OPB) framework appear to have found a place in practice well ahead of empirical support and conceptual clarity. Although the framework is intuitively appealing its inappropriate use may have profound negative implications for patients. Incapacitation and unnecessary treatments may be demanded when observed behaviours are interpreted as evidence of persistent pathology related to previous patterns of criminal offending. Conversely, behaviours occurring within institutions that are not topographically similar but that fall within the same response class and do represent the continuation of problematic patterns of behaviour may be ignored if observers are not sensitive to the possibility that problem behaviours, albeit muted, may persist within institutions. Methods. This paper presents a study examining the similarity of personality disordered patients' violent index acts with their aggressive behaviour during hospitalization. Results. Results revealed evidence of cross situational similarity for some but not all aggressive behaviours. Conclusion. These results provide support for the OPB framework. However, the lack of similarity on a significant number of incidents indicates a need for thorough, structured analysis to determine whether an aggressive behaviour observed in an institution parallels violent acts preceding incarceration. © 2009 The British Psychological Society.
    • A therapeutic community for personality disorder in a high secure intellectual disability service: Inception and early experiences

      Taylor, Jon; Trout, Sarah; Christopher, Janice; Bland, Alan (2012)
      Purpose: This paper seeks to explain the reasons for use of a therapeutic community for personality disorder in a high secure intellectual disability service. Design/methodology/approach: The paper describes the rationale for, and early experiences of, a therapeutic community intervention for people with mild intellectual disability and personality disorder in a high secure setting. Findings: No empirical findings are reported. Evaluation is being undertaken and will be reported in due course. Originality/value: The therapeutic community approach has not been applied in forensic intellectual disability before, and this paper therefore describes an original and, in many ways, radical intervention. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Adapted dialectical behaviour therapy for male offenders with learning disabilities in a high secure environment: Six years on

      Morrissey, Catrin; Ingamells, Bridget (2011)
      Dialectical behaviour therapy (DBT) (Linehan, 1993) is a comprehensive psychological treatment that was first developed for suicidal individuals with a diagnosis of borderline personality disorder. The model has successfully been used to address violence and aggression in a forensic setting (Evershed et al, 2003). The National High Secure Learning Disability Service (NHSLDS) piloted an adapted DBT programme suitable for men with mild learning/intellectual disabilities in 2004, and the programme has been developed over a period of six years. This paper describes the rationale for development of the programme, how the programme has evolved, the major modifications to mainstream DBT that it incorporates, and the challenges that remain.
    • Advanced videogame consoles - A new and unrecognised threat to secure service provision?

      Taylor, Nicholas; Mackay, John (2008)
      Games consoles are ubiquitous in the community, and increasingly in demand in secure forensic psychiatric settings. They contain a range of sophisticated technologies, which may pose a significant security risk, including provision for secure wireless communication, Internet access, playing and duplication of video and audio discs, and storage of large amounts of potentially worrying video and audio content. Staff awareness of this risk is limited by ignorance and the perception that games consoles are ‘toys’ for the use of children and adolescents. This paper highlights the risks related to specific machines and provides guidance on effective management of these risks. (PsycINFO Database Record (c) 2017 APA, all rights reserved) (Source: journal abstract)
    • Ageing in forensic psychiatric secure settings: the views of members of staff

      Di Lorito, Claudio; Dening, Tom; Vollm, Birgit A. (2019)
      ABSTRACTBackground: Although the prevalence of older patients in forensic psychiatric services is increasing, research around service provision for this population is very limited. We aimed to gather the views of members of staff on how well secure services are meeting the challenges of an ageing population.Methods: Three focus groups were carried out with 13 members of staff working with older patients in secure services. A topic guide, based on the research team?s previous research, guided the sessions. The focus groups were audio-recorded, transcribed and analysed through thematic analysis.Results: Two themes were identified: (1) Identifying patients? needs, which focused on how promptly any emerging issues in the older patients are identified and reported; (2) addressing patients? needs, which focused on how the unique needs of the older patients are addressed, once established.Conclusions: There are unique age-related issues that may have an impact on the older patients? opportunities for recovery, including a lack of specialist training for members of staff, prolonged stay in secure care and a limited number of age-relevant activities. Far from optimal, provision requires improvement through the active involvement of the primary stakeholders.
    • Ageing in forensic psychiatric secure settings: The voice of older patients

      Di Lorito, Claudio; Dening, Tom; Vollm, Birgit A. (2018)
      Older patients account for around 20% of the population in secure forensic psychiatric services in the UK. However, little qualitative research has investigated the experience of ageing in secure settings. This study aimed to gather the individual views of a sample of patients over 50 years old in the UK at different levels of security. Fifteen participants were selected and underwent one-on-one qualitative interviews. The interviews were analysed through thematic analysis, which generated seven themes: Self-agency, activities, social life, practical matters, recovery, physical health and service improvement. Study findings highlighted the complexity of ageing in secure settings. Despite the positive feedback reported in aspects such as physical health care, education opportunities, staff and support of religious practices, participants experienced added barriers to recovery, caused by social isolation/withdrawal and activities/treatment that did not respond to their complex age-related needs, generating poor motivation to engage. Our findings call for the development/implementation of programmes tailored to the unique needs of older patients. This process requires an active involvement of the primary stakeholders and further patient-centred research.
    • Ageing patients in forensic psychiatric settings: A review of the literature

      Di Lorito, Claudio; Vollm, Birgit A.; Dening, Tom (2018)
      Objectives: The prevalence of ageing patients in forensic psychiatric settings is increasing. However, limited research has reported around this population. The aim of this scoping review is to synthesise the current evidence around ageing forensic psychiatric patients. Methods: The literature was searched through four databases and Google searches. The identified outputs were screened for suitability and assessed for quality. Quantitative data were extracted and analysed on SPSS; qualitative data were extracted and analysed onto NVivo. Results: Seven studies were included in the review. Quantitative results reported around demographics, service contact, offending patterns, mental, and physical health of ageing patients. Qualitative findings focused on age‐friendliness of services, staff‐patient rapport, activities, security issues, and discharge planning. Conclusions: Ageing forensic psychiatric patients present with complex and unique needs in relation to treatment, activities, mental, physical, and support. Further research looking at individual patients' needs is paramount to inform policy development and good practice in this area.
    • Alcohol and secure hospital patients: I. An examination of the nature and prevalence of alcohol problems in secure hospital patients

      Hodge, John E. (1998)
      The extent and severity of alcohol problems experienced by mentally disordered patients admitted to maximum security hospitals, whilst not included in the criteria for admission, is undoubtedly of relevance and importance in planning the treatment and future disposal of these patients. The study to be described attempts to address such concerns by means of applying an extensive assessment approach with a substantial patient population drawn from three of the four Secure Hospitals within the United Kingdom (n=211). Measures utilised included semi-structured interview, standardised questionnaires and clinical reports contained in case records. Detailed information is provided on weekly consumption levels, problems related to drinking, severity of dependence on alcohol, and use of alcohol at the time of offences. Results highlighted not only the high prevalence, but the extreme severity of alcohol difficulties evident amongst the patient sample, as well as substantial use of alcohol at the time of offences. Future papers will explore further the characteristics of patients with a history of problem drinking and the possible relationship between alcohol and offending. This study represents the first major, detailed and comprehensive assessment of alcohol problems in an extensive sample of secure hospital patients. The implications of these findings for the development of therapeutic services and the future disposal of these patients is emphasised.