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  • Violence risk assessment instruments in forensic psychiatric populations: A systematic review and meta-analysis

    Whiting, Daniel (2023)
    BACKGROUND: 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.
  • Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review

    Sales, Christian P.; Tully, John (2023)
    BACKGROUND: Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. AIM: To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. METHOD(S): Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. RESULT(S): In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. CONCLUSION(S): Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes. Copyright © 2023 John Wiley & Sons Ltd.
  • A community of women in prison: More than a voice – therapeutic use of visual and psychodramatic arts

    Gavin, Vicky (Routledge, 2022)
    This chapter explains the context of the only women's democratic therapeutic community (DTC) in the English prison estate, at Her Majesty's Prison (HMP) Send. Following a brief history, it highlights the importance of recognising distinctive contextual factors reflected in the experience of women–as residents, visitors and staff–by contributions in their own words. Based on staff reports and self-reporting by women like Amaal, the introduction of psychodrama as a core creative therapy (CCT) and its short-term use to support the art therapy frame opened up new therapeutic possibilities for women who feel drawn to drama and embodied ways of working, and also for those to whom this implies a step out of the comfort zone. Psychodrama and art therapy enabled past maladaptive life experiences to be adaptively revisited, through creative experiences with a positive impact on the present and future of DTC residents. Creative warm-up for therapy was deemed important: contained spontaneity was enhanced by these, and potential protagonists were encouraged to take back to their small talking groups the themes they named in the initial part of the psychodrama sessions, or depicted in their art work. Whether these themes were worked through in action or not, art and psychodramatic warm-up exercises, as well as both protagonist and auxiliary role-taking seemed to warm up the women for further therapeutic work in talking groups, enhancing their self-confidence, self-reflection and prosocial relating. CCTs seemed to allow for affirmative adaptive experiences, which reinforced new adaptive ways of thinking, managing emotions and behaving. Adequate support and supervision of the psychodramatist and her participation in staff meetings was deemed crucial for creative group work to flourish in a safe, contained, sustained way, built on and built by the DCT living-learning experience as a whole. The CCT model presented in this chapter is neither static nor prescriptive. The combination and format of the CCTs offered to women in prison have been evolving. The approach adopted, incorporating practice-based evidence and residents’ experiences and reflections, adds to the existing work from male DTCs demonstrating the role of CCTs in enhancing practice and improving outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved) (Source: create)
  • The characteristics, convictions, and incidents of risk of women in the national high secure healthcare service for women

    Clarke, Martin; Williams, Marie; Siddall, Yasmin; Lewis, Jessica (2023)
    Purpose: A service evaluation was conducted to characterise all admissions to the National High Secure Healthcare Service for Women (NHSHSW).Design/methodology/approachData were obtained from computerised records, case notes, and the hospital’s Risk Department. Data collected included the date of incident, incident type, location of incident and name of aggressor. The severity of incidents were reported from 2010 onwards. Some data are presented in three time bands: 2007, 2008–2011, and 2013–2015 in order to illustrate changes. Some data is presented in three age bands based on age at admission: under 30 years old, 30–39 years old and 40 years and over.Findings105 women were admitted into the service between January 2007 and 30 June 2015. The majority of women had a diagnosis of personality disorder (81.0 per cent), a history of trauma (e.g. it was documented that 71.4 per cent had experienced sexual abuse) and had received a criminal conviction (90.5 per cent). A total of 8934 risk incidents were reported and the majority of women (N = 101, 96.2 per cent) were involved in at least one incident during their admission. The majority of recorded incidents involved self-harm (70.9 per cent).Originality/ValueLittle has been published about the NHSHSW population. This article outlines the characteristic profiles of women detained in high secure care.Practical implicationsThe complex background and clinical characteristics highlight the need for trauma-informed practice. Continuous monitoring is required to ensure effective practices.
  • Long-term outcomes after discharge from medium secure care: still a cause for concern?

    Gibbon, Simon D.; McCarthy, Lucy; Clarke, Martin (2023)
    People admitted to medium secure psychiatric care are recognised to still be at risk of experiencing adverse outcomes upon discharge. However, little is known about the outcomes of patients admitted more recently to medium secure care or the long-term outcomes of people many years after discharge. The aim of this study was to assess the mortality, conviction and readmission outcomes of a cohort of first admissions discharged from an English medium secure psychiatric unit between July 1983 and June 2013. Data on background characteristics were obtained from medical records. Outcome data were obtained from multiple sources for 843 patients discharged prior to the census date of 30 June 2013. The risk of death from both natural and unnatural causes was much higher than that of the general population. Of those patients that were discharged, 369 patients (43.8%) were convicted of an offence during the follow-up period, two-thirds of which were convicted within the first 5?years following discharge. Five hundred and ten patients (61.6%) were readmitted to psychiatric care. Patients discharged from medium secure care are at long-term risk of experiencing premature death, conviction and readmission to secure and non-secure psychiatric care.
  • Six nations: A clinical scenario comparison of systems for prisoners with psychosis in Australia, Bolivia and four European nations

    Barlow, Stephan (2022)
    This paper compares across six nations the mental health systems available to prisoners with the highest acuity of psychosis and risk combined with the lowest level of insight into the need for treatment. Variations were observed within and between nations. Findings highlight the likely impact of factors such as mental health legislation and the prison mental health workforce on a nation's ability to deliver timely and effective treatment close to home for prisoners who lack capacity to consent to treatment for their severe mental illness. The potential benefits of addressing the resulting inequalities are noted. Copyright © The Author(s), 2022. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists.
  • Impact evaluation and economic benefit analysis of a domestic violence and abuse UK police intervention

    Kane, Eddie (2023)
    This study evaluated the impact and economic benefit of Cautioning and Relationship Abuse (CARA), an intervention which aims to reduce re-offending of first-time low-level domestic violence and abuse perpetrators. The analysis was based on two samples drawn from separate UK police force areas. CARA’s impact was assessed using a matched sample of similar offenders from a time when CARA was not available. The matching was based on a host of offender and victim characteristics and machine learning methods were employed. The results show that the CARA intervention has a significant impact on the amount of recidivism but no significant reduction in the severity of the crimes. The benefit-cost ratio in both police force areas is greater than one and estimated to be 2.75 and 11.1, respectively, across the two police force areas. Thus, for each pound (£) invested in CARA, there is an economic benefit of 2.75–11.1 pounds, annually.
  • Developing a trauma-sensitive, compassion focused substance misuse treatment intervention for prisoners

    Fehrman, Elaine (2022)
    The aim of this paper is to present a newly developed substance misuse treatment intervention, which has been devised from an extensive review of the literature relating to the prevalence and repercussions of trauma amongst people who use forensic services and use substances. The clinical utility and applicability of integrating Compassion Focused Therapy (CFT) within the context of delivering this new intervention is discussed. As the first pilot is preparing to launch at a high secure site, this paper provides a descriptive, theoretical account of the programme and the rationale for the various components.
  • Knife crime offender characteristics and interventions – A systematic review

    Green, Kathleen (2022)
    Knives and sharp objects are tools used in a wide range of violent offences. However, knife offending may have different risk factors than general violence, thus requiring tailored interventions. This systematic review aims to synthesise evidence on the characteristics of knife offenders and interventions aimed at the reduction of knife crime. After screening 1352 titles and abstracts, 344 articles were fully considered of which 21 papers met the inclusion criteria and were quality assessed. These consisted of 15 offender characteristic studies and six intervention studies. Findings suggested that knife crime may be associated with illicit drug use, exposure to any violence as a witness, victim or perpetrator and mental health problems. Males were more at risk of engaging in knife crime in the community and females in domestic settings. Different risk factors were found between gang involved and non-involved knife offenders. Primary prevention strategies, such as stop and search, knife amnesties, media campaigns and curfews did not show a significant impact in reducing knife crime. By contrast, increasing offenders' access to tailored support regarding housing, education, and employment showed an impact in reducing weapon carrying. Further research is required in the area to support the reliability of outcomes.
  • Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study

    Yates, Jennifer A.; Dening, Tom; Griffiths, Chris; Walker, Kate (2022)
    ObjectivesThere is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this.MethodsSemi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis.ResultsTwo global themes ?What works? and ?What doesn?t work? were identified comprising themes representing environmental, interpersonal and individual factors. ?What works? included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. ?What doesn?t work? included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments.ConclusionsFor older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient?s needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.
  • “Some body else”: Harlequin’s journey in forensic sandplay and gender dysphoria

    Allen, Emma (2021)
    Forensic Sandplay tells tragically ambivalent tales from deep within the unconscious, and body and mind, of devastating physiological and psychological impact of a parental split, abandonment-trauma, loss, and bereavement, from the masculine (and death of the father), and emotional and physical abuse from the feminine (mother). Using both sand trays at a time, Alex’s identity formation existed in the periphery between male and female, and masculine (conscious) and feminine (unconscious) energies in emotional detachment, de-personalisation and over-separation. Sacrificial archetypes, such as Harlequin, surrender the ego to the Self in order for previously masked emotional states, and aspects of Self, to become known, in a process of initiation; containing, liberating, and uniting internal opposing forces, and achieving balance (Jung et al., 1964). As a pretending Fool, yet paradoxically, intelligent Trickster, Harlequin transcends resistance and emancipates suppressed anxieties and threat sensitivity. Through uncovering buried, past resentment, and safely exploring the risk of gender violence, control and rigidity are abandoned in a dual representation of both masculine and feminine forces, in order for self-preservation, adaptation, authenticity, acceptance, and self-realisation. Alex’s separation of body and mind took authority, and desperately sought a sense of agency. Alex’s prohibited sexual and emotional life (perhaps witnessed in hand-printing in the sand) required bodily acknowledgement, and in being seen. (PsycInfo Database Record (c) 2022 APA, all rights reserved) (Source: chapter)
  • Me-thinking: report on a pilot intervention with women in custody

    Gois, Isabel; Kane, Eddie (2022)
    Purpose This pilot study aims to assess the feasibility of conducting shared philosophical inquiry with women at risk of re-offending to improve motivation to change. The philosophy sessions aimed to give participants new ways to think about their lives and to help them have more control over their own mind by learning new ways to think differently. Design/methodology/approach The pilot study adopted a mixed-methods approach to collect and analyse data pre- and post-intervention. Ten women serving a custodial sentence at the Democratic Therapeutic Community (DTC) in HMP Send were recruited to take part in ten weekly sessions of philosophical discussion. The intervention was adjunctive and not meant to replace other treatments an inmate may already be receiving. Findings The results showed that most participants experienced improved levels of well-being and mental health post-intervention, and that the intervention has the potential to help participants better critically assess their own behaviour and ways of thinking. It also suggested that the intervention has the potential to help participants engage more effectively with the therapeutic process. Research limitations/implications The results of this study are limited by the small sample size and the lack of a control group. As such this study cannot rule out that the changes observed in participants were a function of time or the specific therapeutic environment they were in (or both). Originality/value This pilot study is innovative not just for introducing philosophy classes to the women’s prison estate for the first time in England and Wales, but also in its ambition to contribute to the “what works” agenda in offender rehabilitation.
  • "When you have got like twenty thousand thoughts in your head, that one little thing can just make it all go away": Trauma and non-suicidal self-injury in forensic settings

    Beryl, Rachel; Lewis, Jessica (2022)
    This chapter explores the relationship between trauma and non-suicidal self-injury (NSSI) within forensic settings. In particular, it considers prevalence rates, pathways to NSSI, and the dual risk presented by those who engage in both NSSI and violence. The primary reference group for this chapter is those in the National High Secure Healthcare Service for Women (NHSHSW) and it considers responses within this setting to understand, manage, and reduce the occurrence of NSSI, considering the impact of these on both staff and patients. The chapter advocates Trauma-Informed treatment responses for this population, drawing on the Trauma and Self-Injury (TASI) service. Interwoven throughout the chapter are the lived experiences of patients, using the patients voice as part of the narrative.
  • Early trauma, psychosis, and violent offending

    Callender, Naomi (2022)
    Psychosis tends to be an experience that socially isolates the sufferer and generates fear and distance in others. This is likely intensified when this presentation is combined with offending. In this chapter, using case examples we describe the possible pathway to psychosis through trauma and the links to violence. We illustrate the function and method in “madness”, clear evidence for the need to understand, and make sense of, what is being communicated through delusional and/or psychotic experience, and the importance of looking beyond diagnostic frameworks. In doing so, we can explore the function of hypervigilance, the parallels with childhood experience, and the efforts to avoid further victimisation.
  • Trauma, personality disorder, and offending

    Sainsbury, Louise (2022)
    This chapter provides an overview of the presence and relevance of childhood traumas in the histories of individuals who have been given a diagnosis of personality and offended. A summary of the impact of childhood traumas, adverse attachments, and adversity and the lack of relational security on individuals’ personality development is described in relation to the diagnostic traits for personality disorders and dynamic risk factors. A service user provides his narrative of the impact of childhood attachment adversity and traumas on his development, mental health, and offending and describes what has been significant in supporting his recovery journey so far. The significant overlap across these areas and the increasing recognition of the need to understand developmental antecedents of individuals’ mental health difficulties and offending are highlighted. Current psychological treatment approaches across forensic services, including those based on a developmental model, are briefly described and the application of Schema Therapy for individuals who have been given a diagnosis of personality disorder and offending is discussed. Overall, the importance of asking individuals what has happened to them and developing a shared understanding of the impact of what happened to them is considered fundamental to supporting development and risk reduction.
  • Trauma and intellectual disability

    Longfellow, Emma; Hicks, Rachel (2022)
    Individuals with Intellectual Disabilities (ID) are exposed to higher rates of adverse experiences in childhood than those without ID. However, there is also an under-reporting of trauma-related disorders in this population, possibly attributed to communication deficits in those who experience it and diagnostic overshadowing. These issues are further compounded when exploring the role of trauma and offending in this population due to legal and social variations in what constitutes challenging versus criminal behaviour. This chapter looks to draw together our current understanding in this area, its implications for clinical practice, and provides a case example.
  • Deafness and trauma: A journey to equitable trauma-informed care

    Todd, Sarah (2022)
    This chapter explores the unique relationship between Deafness and trauma and emphasises the fundamental need for an equitable and inclusive trauma-informed care for Deaf people in forensic services. It describes the prevalence of trauma in the Deaf population, the trauma experience of many Deaf children and the unique characteristics of trauma experienced in the Deaf population. The chapter also offers key insights into the experience of being Deaf in the Criminal Justice System, highlighting that Deaf individuals are often vastly overrepresented (and often stuck) within it. The chapter explores in detail what is needed to achieve equity in trauma care for Deaf people in forensic services. The chapter aims to promote the importance of a resilience – and a strength – orientated approach to care that produces balance between retribution and rehabilitation, resilience and empowerment in a system that has re-traumatised Deaf people for too long. This chapter emphasises need for equality in research, strategy, delivery, and evaluation.
  • From care to custody?

    Woodall, Tamara (2022)
    This chapter explores the social care system’s role in trauma and adversity experienced by young people in care and the potential impact on the trajectory from care to custody. We include the unique perspectives of care-experienced individuals and highlight a need for more research that captures the voices of a marginalised population. Finally, we provide recommendations for practitioners and policy makers to embed trauma-informed care and identify bottom-up and top-down processes to ensure a more integrated, proactive, and compassionate system.
  • Trauma and sexual offending: Causal mechanisms and change processes

    Jones, Lawrence F. (2022)
    In the past trauma has been as an area to be avoided in working with people who have offended sexually because it was seen as providing individuals with exculpatory narratives. In this chapter an alternative view to this will be examined. The chapter explores a range of pathways linking different kinds of experience of adversity, oppression, and trauma and sexual offending. The utility of making sense of the developmental context of offending in order to facilitate interventions and developing case formulations will be explored. A range of interventions that focus on different biological, psychological, and social, trauma-derived processes in the lives of people who have offended sexually are explored.

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