• Supervision as an intervention with mentally disordered offenders: Some observations

      Ousley, Leah; Robinson, David K. (2002)
      The supervision of mentally disordered offenders at risk of harm to themselves or others is universally practised, but there is little research evidence in the literature as to how, in what circumstances, with which patients, to what end and with what results for the patient and/or staff. This article reviews the available evidence on the practice and calls for evidence based guidelines for the role inherited by nurses to inform effective practice.It concludes:* empirical evidence is lacking on the supervision of mentally disordered offenders as an effective nursing intervention* there is evidence of ambiguity as regards psychiatric nursing interventions* supervision of mentally disordered offenders is subject to covert and inconsistent practice* there is a need for research on which to base training, skill mix decisions and the general management of supervision.
    • Developing competency-based programmes in a high secure setting

      Gordon, Neil; Tennant, Allison (2002)
      This paper describes and analyses our experiences as lecturer practitioners working in the personality disorder service at Rampton High Secure Hospital. This service is an NHS Beacon site and hosts one of the pilot projects that are part of the Home Office and Department of Health initiative concerned with the assessment and treatment of people deemed to be dangerous because of the severity of their personality disorder. The paper focuses on the development of a competency-based diploma/degree programme that is integrated with service priorities and clinical care pathways. The factors that shaped the evolution of this programme are outlined, supplemented by a critical commentary on how the course team experienced and made sense of the complex dynamics of the implementation process. Also discussed is the way our experience of facilitating dialectical behaviour therapy (DBT) group work influenced and helped us understand our work with students. Being active in service delivery ensured the course content developed from and reflected the realities of clinical practice. These issues are discussed with reference to the concept of parallel processes (Hawkins & Shohet, 2000) and by comparing the clients' experience of DBT groups with the students' experience of the competency programme.
    • The voice of detainees in a high security setting on services for people with personality disorder

      Ryan, Sue (2002)
      BACKGROUND: British government Home and Health Departments have been consulting widely about service development for people with ' dangerous severe personality disorder' (DSPD). There has, however, been no consultation with service users, nor is there any user view literature in this area.
    • Meeting patients' needs in secure forensic psychiatric units

      Ashwell, Chris (2003)
      The authors have developed a security needs assessment profile designed to match the service provided in secure, forensic psychiatric units more accurately with the needs of individual patients. They are carrying out an 18-month survey of all secure units in England and are seeking participants to help refine the profile, gain more understanding of what is provided throughout the country, and assess the views of other clinicians and managers.
    • Exploring core relationships between insight and communication and social skills in mentally disordered offenders

      Collins, Mick (2003)
      This paper reports collective data analysis for the Behavioural Status Index insight and communication and social skills subscales. This is an instrument designed specifically for health care practitioners to measure behavioural and social functioning among mental health clients, in particular those in forensic care. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high security mental health hospitals in the UK. Results are reported for interscalar item correlations and factor analysis. Data trends are indicative of clinically interesting relationships. A six-factor structure emerged suggesting groupings of intra- and interscalar behaviours. The first of these contained all the Behavioural Status Index insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. According to Mental Health Act 1983 classifications, psychopathically disordered patients scored more normatively than mentally ill patients, who in turn scored more normatively than patients with learning disability. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association to treatment planning are discussed.
    • Differences in the progress of discharged and undischarged patients in a medium secure unit: A pilot study

      Heap, Michael (2003)
      This study compared 15 patients ('undischarged' group) who were showing little sign of progress in a medium secure unit (MSU) after 2 years with 15 who had been discharged from the same unit 1-2 years following admission. The two groups were compared across a number of broadly defined behavioural indices during their first 6 months and first 12 months following admission. The measures used were indices of progress to wards of lower security (highest ward status and transfers to wards of higher security) and progress in terms of leave (highest leave status and reductions in leave status). In addition, the two groups were compared on number of recorded incidents attributable to them. Discharged patients were significantly older at the time of their admission than the undischarged patients (median ages 33 and 26 years, respectively). They made more progress in their first year in terms of ward security and leave status and were responsible for fewer recorded incidents. These results were also obtained at 6 months following admission with the exception that the difference for highest ward status was not statistically significant. The findings of this small-scale study suggest that within the first 6 months of admission, it may be possible to distinguish patients who will probably make good progress in a MSU from those whose progress is likely to be very slow. Implications of the study are discussed.
    • The relationship between risk and insight in a high-security forensic setting

      Collins, Mick (2003)
      It is often intimated amongst practitioners in mental healthcare that clients who display poor insight either into their mental health or behaviour present a greater risk either to themselves or others. This paper reports relationships found between the risk and insight subscales of the Behavioural Status Index. This is an instrument designed specifically for healthcare practitioners to measure health functioning amongst mental health clients, in particular those in forensic mental healthcare. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high-security mental health hospitals. Seven factors emerged through factor analysis. The first of these contained all the insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association with treatment planning are discussed.
    • Referred to high secure care: Determinants of a bed offer/admission and placement after one year

      Larkin, Emmet P.; Watson, Neil; Duggan, Conor (2003)
      Background: The admission process to high secure care ought to ensure that those admitted (a) receive mental health care that meets their needs and (b) that this is provided at an appropriate level of security. Aims: A study was undertaken to test the effectiveness of the gate keeping process according to these two criteria. Method: All referrals for admission to Rampton high security hospital over one year were examined and, in addition, all women, all Anglo-Caribbeans and a random 50% sample of the Caucasian male majority were selected for interview. Each case was followed up for 12 months following the panel decision to determine his/her placement at that time. Results: Of 138 referred, 56 (41%) were initially offered a bed although nearly half (66) had been subsequently admitted by the end of the study period. Seriousness of mental disorder and offence were independently associated with admission. After one year, one third of those admitted were no longer in high secure care. Conclusions: The variables predictive of admission (i.e. seriousness of both mental disorder and offence) suggest that the decision-making process was valid. Placement at 12 months tended to endorse the decision not to offer a bed, but it is more difficult to interpret the reverse as short admissions to high security for those who left within 12 months may have been appropriate. There was no apparent advantage in having a panel reviewing the decision of the assessing clinician.
    • Substance use disorders in patients admitted to a medium secure unit: A comparison of three assessment measures

      Bloye, Darran (2003)
      The presence of co-morbid substance use disorders among individuals suffering from a severe mental illness has an adverse effect on risk-related behaviour and prognostic indicators. Using a multi-assessment approach, the study examined the prevalence and risk consequences of substance use disorders in the population of a medium secure unit, by comparing the assessments of professionals and the participants' self-reports. A sample of 58 inpatients was assessed using the severity of dependence scale (SDS), clinician rating scales (CRS), and a case-note questionnaire. For each assessment tool, a majority of the sample recorded a history of substance use disorder and risk-relevant substance use. The morbidity related to individual substances varied and there was support for the self-medication hypothesis of secondary substance misuse. Subjects identified by professionals as having problematic substance use appeared to have disproportionately avoided participation in the study, whereas the professionals did not differ significantly in their diagnosis of rates of substance use disorder. A multi-assessment approach enables a more comprehensive assessment of substance use disorders within a forensic population and this study further highlights the importance of developing therapeutic strategies for dual diagnosis patients.
    • Personality traits, personality disorders and sensational interests in mentally disordered offenders

      Elliot, Debbie; Patel, Darshana; Charlesworth, Philip (2003)
      Purpose. Sensational interests (e.g. an interest in the occult or the methods of violence) in mentally disordered offenders are claimed to signify greater risk of psychopathology, but evidence to support this view is slight. Methods. The relationships between self-reported DSM-IV personality disorder (PD), general personality traits and sensational interests were examined in 155 of 167 consecutively referred offenders to a forensic psychology service. The subscales of the PD and personality trait measures were reduced to the four basic PD/trait dimensions (asocial, antisocial, anxious and anankastic) using confirmatory factor analysis. Results. Those high on the 'antisocial' factor (which was primarily defined by low Agreeableness, low Conscientiousness, and substantial elements of Paranoid, Antisocial and Borderline PD) were more interested in 'violent-occult' and militaristic topics. Conclusions. The aspects of the antisocial factor primarily associated with an interest in sensational and potentially violent topics cover a wide range of putative disorders. However, the factors reflecting asocial, anxious or anankastic disorders do not show a reliable association with measures of sensational interests. These results suggest that the personality dimensions reflecting an interest in 'sensational' topics in mentally disordered offenders are relatively specific.
    • The individual needs of patients in high secure psychiatric hospitals in England

      Middleton, Hugh (2004)
      A comprehensive assessment of the needs of all high security psychiatric hospital (HSPH) patients in England has not previously been conducted. All inpatients in the three HSPHs in England (Ashworth, Broadmoor and Rampton, n = 1256) were assessed. Factors associated with placement need were modelled using logistic regression, then cluster analysis was used to identify patient subgroups on the basis of their individual needs. Forty percent of the patients could be transferred out of high security, according to the RMOs. While it was possible to identify factors associated with the continued need for high security the false negative rate was high. Patients had very diverse needs that did not fit neatly into clustered subgroups. Due to the heterogeneity of the individual patients currently in the HSPHs, future service planning will need to focus on individualized treatment packages that are based on individual assessments of need. Such assessments should be considered in the wider framework of risk and accountability. © 2004 Taylor & Francis Ltd.
    • The security, clinical and social needs of patients in high security psychiatric hospitals in England

      Jones, Peter (2004)
      Previous studies have indicated that between one and two thirds of patients in the high security psychiatric hospitals (HSPHs) could be transferred to lower security. The aim of this study was to measure the individual and placement needs of all patients in the three HSPHs in England. In total 1255 patients were assessed using staggered census dates. Five hundred (40%) patients were rated as suitable for transfer to lower security. Long-term medium and low security facilities constituted over half of the recommended alternative placements. Unmet needs for the total population were most frequently reported with daytime activities, substance misuse, sexual offending, safety to others, and psychotic symptoms. Most clinical and social needs were met. High secure Responsible Medical Officers (RMOs) reported that 500 patients could be transferred immediately to lesser levels of hospital security if such facilities existed. However 60% of patients were rated as continuing to require high secure care therefore special hospitals, or their equivalent, continue to be needed for the foreseeable future in England. © 2004 Taylor & Francis Ltd.
    • The birthing pains of Cedars Community: Developing a therapeutic community for patients with schizophrenia in a high security hospital

      Davies, Steffan; Mooney, Paul (2004)
      This paper describes the process of developing a therapeutic community (TC) for patients with schizophrenia in a high security psychiatric hospital. Whilst TCs exist in secure settings they are almost exclusively for those with personality disorder whereas TCs for people with psychosis exist predominantly in the community. This is possibly the first attempt to set up a TC for patients with psychosis in a high security hospital. The paper begins by considering the infiuence of various higher order systems. We then discuss the process of developing the service and the tensions between the traditional consultant role and TC working. The paper concludes by questioning whether we are a TC by referring to basic TC principles, the Ward Atmosphere Scale and the Service Standards for TCs. © The Authors.
    • Defining the needs of patients with intellectual disabilities in the high security psychiatric hospitals in England

      Johnston, Susan J.; Middleton, Hugh (2004)
      Background Previous studies have suggested that a substantial proportion of the patients with intellectual disabilities (ID) in the high security psychiatric hospitals (HSPHs) should be transferred to more appropriate services to cater for their specific needs in the longer term. Method The individual and placement needs of high secure psychiatric patients detained under the legal category of mental impairment or severe mental impairment were assessed in a cross-sectional survey. Results Patients had a large number of needs (on average 10.8), about a third of which were rated as unmet and therefore represented significant continuing problems. Approximately one-third of the sample could be moved out of HSPHs if appropriate alternatives were available. Factors associated with the continued need for high security included higher treatment and security needs, younger age, recent violent conduct and their index offence profile. Conclusions High security services are still required for a number of patients with ID. New and existing services need to be configured to meet specific profiles of need and provide long-term rehabilitation and specialist care. Declaration of interest This was part of a larger project funded by grants from the High Security Psychiatric Services Commissioning Board and Department of Health.
    • Parental loss before the age of 16 years: A comparative study of patients with personality disorder and patients with schizophrenia in a high secure hospital's population

      Pert, Linda; Ferriter, Michael; Saul, Cleopatra (2004)
      There is a considerable body of literature supporting an association between separation from parent in childhood and later personality disorder. This study compares a 10-year cohort of high secure hospital patients who had either a personality disorder or schizophrenia, but with no other significant psychiatric comorbidity. The information source was the Special Hospitals Case Register. The most important finding was a statistically significant difference in the rates of child-parent separation between the two groups. In the personality disorder group, 119/147 (81%) of the patients had been separated from one or both parents before the age of 16 compared to 178/289 (62%) in the schizophrenia group.
    • Managing problematic anger: The development of a treatment program for personality disordered patients in high security

      Jones, David (2004)
      Anger can present as a significant component in the expression of aggression and violence. Anger management is one therapeutic approach that has recorded some success in reducing levels of anger. However, there is a lack of studies that examine the efficacy of anger management with mentally disordered offenders. The present study reviews the development and implementation of an anger management program specifically designed for mentally disordered offenders in a high security setting. Eight male patients who exhibited aggressive behavior within the hospital and had a significant anger problem participated in a 36-week treatment program. The design of the program was successful in ensuring a low dropout rate. Patients were assessed in relation to the frequency and intensity of anger incidents and on a number of psychological variables. Repeated assessment showed positive changes on these measures both during the program and at follow-up. There was a significant reduction in both the frequency and intensity of anger incidents during treatment, which was maintained at 4-week follow-up. The findings are preliminary but encouraging in suggesting that both the style of the program and the evaluation strategy may be appropriate for aggressive mentally disordered offenders within high security settings. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Relationships among risk, and communication and social skills in a high security forensic setting

      Collins, Mick (2004)
      The Behavioural Status Index was developed for risk assessment within forensic care. This paper reports data analysis for the Behavioural Status Index and its subscales. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 individual patients in two high security mental health hospitals in the UK. Results are reported for inter-item correlations, factor analysis, and differences among independent groups of patients, categorized by Mental Health Act 1983 classification, patient ward dependency, and patient gender. Data trends are indicative of clinically interesting relationships. A distinct factorial structure emerged suggesting groupings of behaviours.
    • Potential effects of retraction of the high-security hospitals

      Davies, Steffan (2005)
      The high-security hospitals are undergoing a retraction process. In conjunction with this, regional services are being developed for those patients who require longer term treatment at medium-security units. This paper aims to provide an overview of the issues involved, along with the background against which these changes are taking place and the uncertainties involved in the process. This current paper will use the information available from the Fender reports and other evidence to examine potential implications of the major changes that are underway in the high-security hospitals. Major changes are taking place in prison healthcare that will impact upon the demand for beds in both mediumand high-security units. The impact upon the prison sector of inadequate numbers of high-security beds is likely to be serious. The high-security hospitals provide treatment for the most challenging and complex minority of prisoners transferred into the healthcare system. There is a risk that the manpower needs across all disciplines will have a negative impact upon other parts of mental health services which may already be struggling to recruit and retain staff. There is a need for the commissioning process to become more clinically informed and the complexity and inherent risks to be acknowledged and taken into account in the planning process.
    • The prevalence of early onset alcohol abuse in mentally disordered offenders

      Howard, Richard C. (2005)
      The alcohol consumption histories of 563 male patients resident at Broadmoor Hospital over the period 1997-2002 were ascertained from inspection of patients' case files. Information regarding alcohol consumption was obtained from patients' forensic and psychiatric reports and, for a sub-set of the sample (n=101), from reports of drug and alcohol assessments. Patients were grouped according to whether or not they had abused alcohol (consumed greater than 50 units per week) and, if so, by age of onset of their alcohol abuse: prior to age 19, 19-21, or over 21 years. Forensic and psychiatric reports indicated that 47.4% of the sample had abused alcohol and 22.0% started to abuse before the age of 19. The 70.3% of patients who underwent drug and alcohol assessment were found to have abused alcohol and 48.5% had abused alcohol under the age of 19. These findings underline the high prevalence of early onset alcohol abuse among high-security mentally disordered offenders, and indicate the need for studies that address the intervening variables that mediate the link between teenage alcohol abuse and adult antisocial behaviour. © 2005 Taylor & Francis.