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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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Defining health management: A conceptual foundation for excellence through efficiency, sustainability and equityThe practice of healthcare management is essential for the efficient operation of health services, encompassing leadership, management, and direction within healthcare organisations. 'Health management' extends beyond healthcare management by integrating principles of public health and health policy. As health management is commonly practised but not cohesively recognised, the European Health Management Association (EHMA) conducted this study to develop a cohesive definition of health management. Developed through a qualitative methodology comprising focus group discussions and validation through quantitative expert interviews, this study proposed a holistic definition of health management, incorporating social, environmental and economic determinants of health, cross-sector collaboration, and the 'One Health' approach. The publication of this unified definition has important implications for professional training, policy development, and health outcomes. It provides a foundational framework for curricula, informs precise policy formulation, and promotes excellence through health service delivery that reflects efficiency, sustainability, and equity.
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Bridging the gap: A qualitative study exploring the impact of the involvement of researchers with lived experience on a multisite randomised control trial in the national probation service in England and WalesINTRODUCTION: Methodological and ethical arguments support the involvement of individuals with lived experience in research to reduce engagement barriers and ensure those directly affected by studies contribute to knowledge generation. However, there is limited evidence on the impact of including researchers with lived experience of serving a prison or community sentence in clinical trials. This qualitative study aimed to explore the value of involving researchers with lived experience of the criminal justice system as data collectors in the Mentalization for Offending Adult Males (MOAM), a multisite RCT conducted in the National Probation Service in England and Wales. METHODS: Semi-structured interviews were conducted with 30 trial participants and 17 key stakeholders, either in person or via telephone. The interviews were transcribed verbatim and analysed thematically. FINDINGS: Five themes emerged for trial participants and 11 for key stakeholders. For some, lived experience researchers helped overcome engagement barriers by fostering common ground with participants who were serving a prison or community sentence during recruitment. Participants reported that the involvement of lived experience researchers enhanced the study by facilitating knowledge transfer in certain instances. However, their inclusion did not eliminate all barriers and, for some participants, introduced new challenges to engagement. CONCLUSION: Forensic lived experience researchers bridged the gap by fostering trust between data collectors and participants. Future studies should ensure that lived experience researchers receive adequate clinical supervision to support their role. The adopted methodology challenged assumptions about knowledge generation and stereotypes associated with being an ex-offender, benefiting both lived experience and traditional researchers. PATIENT OR PUBLIC CONTRIBUTION: The study was developed in collaboration with User Voice (charity number: 1136047), who contributed to the study's design and conduct. The service user organisation co-designed the interview schedule and directed the protocol for participant payments, emphasising a consistent approach to avoid tokenism and ensure equal recognition of all contributions. The dissemination plan was developed in partnership with individuals with lived experience of the criminal justice system.
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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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Line manager training and organizational approaches to supporting well-beingBACKGROUND: Employee mental health and well-being (MH&WB) is critical to the productivity and success of organizations. Training line managers (LMs) in mental health plays an important role in protecting and enhancing employee well-being, but its relationship with other MH&WB practices is under-researched. AIMS: To determine whether organizations offering LM training in mental health differ in the adoption of workplace- (i.e. primary/prevention-focused) and worker-directed (including both secondary/resiliency-focused and tertiary/remedial-focused) interventions to those organizations not offering LM training and to explore changes in the proportions of activities offered over time. METHODS: Secondary analysis of enterprise data from computer-assisted telephone interview surveys. The analysis included data from organizations in England across 4 years (2020: n = 1900; 2021: n = 1551; 2022: n = 1904; 2023: n = 1902). RESULTS: Offering LM training in mental health was associated with organizations' uptake of primary-, secondary-, and tertiary-level MH&WB activities across all 4 years. The proportion of organizations offering primary-, secondary- and tertiary-level interventions increased over time. On average, tertiary-level activities were most adopted (2020: 80%; 2021: 81%; 2022: 84%; 2023: 84%), followed by primary-level activities (2020: 66%; 2021: 72%; 2022: 72%; 2023: 73%) and secondary-level activities (2020: 62%; 2021: 60%; 2022: 61%; 2023: 67%). CONCLUSIONS: Offering LM training in mental health is associated with the adoption of other MH&WB practices by organizations. Suggesting that organizations that are committed to the mental health agenda are more likely to take a holistic approach (including both worker and workplace strategies) to promoting workforce mental health, rather than providing LM training in isolation.
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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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Early vocational rehabilitation and psychological support for trauma patients to improve return to work (the ROWTATE trial): Study protocol for an individually randomised controlled multicentre pragmatic trialBACKGROUND: Moderately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma. METHODS: ROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants' self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere. DISCUSSION: This trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS. TRIAL REGISTRATION: ISRCTN: 43115471. Registered 27/07/2021.
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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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Inclusivity and decolonisation of the post-graduate public health curriculum: Reflections from a student-led approachThe future of successful public health practice requires public health students to be educated within a decolonised curriculum that challenges the historical biases and inequalities that are deeply embedded within global public health and society. In this commentary, we reflect on what it can mean and why it's important to decolonise and diversify a public health curriculum. We describe how we used a student-led approach to begin this process, and share recommendations that are applicable to national and international curricula.
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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.
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The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offendersBACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.
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Violence risk assessment instruments in forensic psychiatric populations: A systematic review and meta-analysisBACKGROUND: Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered. METHODS: In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716. FINDINGS: We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I(2)=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I(2)=0%) and Violence Risk Appraisal Guide (0·63-0·75; I(2)=0%), to 0·64 for the Static-99 (0·53-0·73; I(2)=45%). INTERPRETATION: Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support. FUNDING: Wellcome Trust.
